You can provide this authorization by signing a form SSA-827. Federal law permits sources with information about you to release that information if you sign a single authorization to release all your information from all your possible sources. 475 20 U.S. Code section 1232g FERPA 34 CFR parts 99 and 300 and State law. Form SSA-827 11-2012 ef 11-2012 Use 4-2009 and Later Editions Until Supply is Exhausted Page1 of 2 Explanation of Form SSA-827 Authorization to Disclose Information to the Social Security Administration SSA We need your written authorization to help get the information required to process your claim and to determine your capability of managing benefits. SSA makes every reasonable effort to ensure that the information in the SSA-827 is provided to you in your native or preferred language. Form Approved OMB No* 0960-0623 WHOSE Records to be Disclosed NAME First Middle Last Suffix SSN - Birthday mm/dd/yy AUTHORIZATION TO DISCLOSE INFORMATION TO THE SOCIAL SECURITY ADMINISTRATION SSA PLEASE READ THE ENTIRE FORM BOTH PAGES BEFORE SIGNING BELOW I voluntarily authorize and request disclosure including paper oral and electronic interchange OF WHAT All my medical records also education records and other information related to my ability to perform tasks. This includes specific permission to release 1. All records and other information regarding my treatment hospitalization and outpatient care for my impairment s including and not limited to Psychological psychiatric or other mental impairment s excludes psychotherapy notes as defined in 45 CFR 164. 501 Drug abuse alcoholism or other substance abuse Sickle cell anemia Records which may indicate the presence of a communicable or noncommunicable disease and tests for or records of HIV/AIDS Gene-related impairments including genetic test results 2. Information about how my impairment s affects my ability to complete tasks and activities of daily living and affects my ability to work. 3. Copies of educational tests or evaluations including Individualized Educational Programs triennial assessments psychological and speech evaluations and any other records that can help evaluate function also teachers observations and evaluations. 4. Information created within 12 months after the date this authorization is signed as well as past information* FROM WHOM All medical sources hospitals clinics labs physicians psychologists etc* including mental health correctional addiction treatment and VA health care facilities All educational sources schools teachers records administrators counselors etc* Social workers/rehabilitation counselors Consulting examiners used by SSA Employers insurance companies workers compensation programs Others who may know about my condition family neighbors friends public officials TO WHOM PURPOSE THIS BOX TO BE COMPLETED BY SSA/DDS as needed Additional information to identify the subject e*g* other names used the specific source or the material to be disclosed The Social Security Administration and to the State agency authorized to process my case usually called disability determination services including contract copy services and doctors or other professionals consulted during the process.
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What Is ssa 827?
This document is required by the Social Security Administration to determine whether the applicant is disabled. The medical and other information is necessary to be provided to the success of the disability programs. If you intend to authorize the disclosure to the local authorities in order to apply for benefits, you should complete this SSA-827 form. It serves as a part of the disability application. No matter, whether you are an adult or you want to report about childhood ailment. This form may be used to as a written request of the claimant to a medical or another source to release information about infirmary. This way an individual may get an authorization for the claimant’s sources to provide information to the Social Security Administration. The sources include hospitals, doctors, schools, nurses, psychiatric workers, employers, friends, and family members.
It is more efficient to fill out the form SSA-827 online than to apply over the telephone or in person. Just insert your personal data into the fillable fields. There should be your contacts mentioned on the right top corner of the first page. Identify whose records to be disclosed
Include the following lines:
Name (first, middle, last, suffix)
Your social security number
Before signing check the document for mistakes and ensure, that every field is completed. It is possible to personalize the document using editing tools and send to sign it electronically. You can export your file in PDF to any other format if needed. Save it and print to have a paper copy.
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