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Social Security Administration Consent for Release of Information (Form SSA-3288)

The Social Security Administration Consent for Release of Information, also known as “Form SSA-3288”, is a document that is used to provide official, written permission for a groups such as a doctor, insurance company or any other group who may require specific information for a  person, caregiver for an incompetent adult, to assist in acquiring needed financial assistance or even various other needs such as (example) electric wheel chairs or other needed prosthetics.

It’s very important that  all fields must be properly completed, as the document could be delayed as a result, if the fields are left incomplete.

How to Write

Step 1 – Download the entire document

  • The applicant must carefully review all of the information provided on the first page, to ensure a clear understanding  with regard to what is needed to ensure that the agency will have from you what will be needed to properly expedite the needs of the applicant.
  • If the document is too difficult to understand, the applicant may either call the Social Security Office or visit their local office for more thorough assistance.

Step 2 – On the second page, submit the following on behalf of the applicant:

  • Full name
  • Date of Birth in mm/dd/yyyy format
  • Social Security Number

Step 3 – Authorize release of the applicant’s documents or records, to be sent directly to the Social Security Administration by having the information to:

  • The names of the persons or organizations
  • Enter the reason, into the line provided, as to why the information must be released

Step 4 – Specify the information from the list that must be released – Check at least one of the boxes provided as follows:

  • Social Security Number
  • Current SS benefit amount
  • Current SSI monthly payment amount
  • Benefit amounts from mm/dd/yyyy to mm/dd/yyyy
  • Medicare entitlement from mm/dd/yyyy to mm/dd/yyyy format
  • Medical Records from claims folder(s) from mm/dd/yyyy to mm/dd/yyyy format – (Contact local social security office for proper forms for minor child)
  • Complete medical records from claim folder(s)
  • Other records from files – specify on lines provided

Step 5 – Signatures

The applicant must carefully read and agree to the entire section stated, regarding the form prior to signature and then provide the following:

  • Applicant’s signature as self or caregiver
  • Date of signature in mm/dd/yyyy format
  • Complete address
  • Relationship to applicant (if this information is not on record)
  • Daytime telephone number

Witness must only sign if the applicant’s signature is an “X” or some other dedicated mark:

  • Signature of witnesses
  • Complete addresses of  witnesses complete with zip code

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