Form SSA-827 (06-2024), Authorization to Disclose Information to the Social Security Administration (SSA) Instructions
This form contains 26 fields organized into 9 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Disclosed Person's Information | ||
| Disclosed Person's Name | Text |
Enter the full name of the person whose records are to be disclosed, including first, middle, last, and any suffix.
|
| Disclosed Person's SSN | Text |
Enter the Social Security Number of the person whose records are to be disclosed.
|
| Disclosed Person's Birthday | Date |
Enter the birthday of the person whose records are to be disclosed.
|
| First Witness Information | ||
| First Witness Signature | Text |
Enter the signature of the first witness.
|
| First Witness Phone Number or Address | Text |
Provide the phone number or address for the first witness.
|
| Individual Authorizer Information | ||
| Individual Authorizer Signature | Text |
Enter the signature of the individual authorizing the disclosure.
|
| Date Signed | Date |
Enter the date this authorization was signed.
|
| Street Address | Text |
Enter the street address of the individual authorizer.
|
| Phone Number | Text |
Enter the phone number of the individual authorizer, including the area code.
|
| City | Text |
Enter the city of the individual authorizer.
|
| State | Text |
Enter the state of the individual authorizer.
|
| ZIP Code | Text |
Enter the ZIP code of the individual authorizer.
|
| Page 2 | ||
| This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical, educational, and other information under P.L. 104-191 ("HIPAA"); 45 CFR parts 160 and 164; 42 U.S. Code section 290dd-2; 42 CFR part 2; 38 U.S. Code section 7332; 38 CFR 1.475; 20 U.S. Code section 1232g ("FERPA"); 34 CFR parts 99 and 300; and State law. Page 2 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. Laws and regulations require that sources of personal information have a signed authorization before releasing it to us. Also, laws require specific authorization for the release of information about certain conditions and from educational sources. 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. We will make copies of it for each source. A covered entity (that is, a source of medical information about you) may not condition treatment, payment, enrollment, or eligibility for benefits on whether you sign this authorization form. A few States, and some individual sources of information, require that the authorization specifically name the source that you authorize to release personal information. In those cases, we may ask you to sign one authorization for each source and we may contact you again if we need you to sign more authorizations. You have the right to revoke this authorization at any time, except to the extent a source of information has already relied on it to take an action. To revoke, send a written statement to any Social Security Office. If you do, also send a copy directly to any of your sources that you no longer wish to disclose information about you; SSA can tell you if we identified any sources you didn't tell us about. SSA may use information disclosed prior to revocation to decide your claim. It is SSA's policy to provide service to people with limited English proficiency in their native language or preferred mode of communication consistent with Executive Order 13166 (August 11, 2000) and the Individuals with Disabilities Education Act. SSA makes every reasonable effort to ensure that the information in the SSA-827 is provided to you in your native or preferred language | Text | |
| Privacy Act Statement. Collection and Use of Personal Information. Sections 205(ay), 223(d), 1614(ay), and 1631(d) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from making an accurate and timely decision on your claim, and could result in a denial or loss of benefits. We will use the information you provide to determine your eligibility or continuing eligibility of benefits, and your ability to manage any benefits that you currently receive. We may also share the information for the following purposes, called routine uses: • To State audit agencies for the purpose of: (a) auditing State supplementation payments and Medicaid eligibility considerations; and (b) expenditures of Federal funds by the State in support of the Disability Determination Services; and • To third party contacts, where necessary, to establish or verify information provided by representative payees or representative payee applicants. In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs. Ay list of additional routine uses is available in our Privacy Act System of Records Notices (S O R Ns) 60-0089, entitled Claims Folders System, as published in the Federal Register (F R) on October 31, 2019, at 84 F R 5 8 4 2 2; 6 0-0 0 9 0, entitled Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 F R 1 8 2 6; 6 0-0 1 0 3, entitled Supplemental Security Income and Special Veterans Benefits, as published in the F R on January 11, 2006, at 71 F R 1 8 3 0; and 6 0-0 3 2 0, entitled Electronic Disability (e D I B) Claim File, as published in the F R on June 4, 2020, at 85 F R 3 4 4 7 7. Additional information, and a full listing of all of our S O R Ns, is available on our website at w w w.s s ay.g o v/privacy | Text | |
| Paperwork Reduction Act Statement. This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA’s website at w w w.social security.g o v. Offices are also listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-8 0 0-7 7 2-1 2 1 3 (T T Y 1-8 0 0-3 2 5-0 7 7 8). You may send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security B l v d, Baltimore, M D 2 1 2 3 5-6 4 0 1. Send only comments relating to our time estimate or other aspects of this collection to this address, not the completed form | Text | |
| You have reached the end of the form. If you tab out of this field you will return to the beginning of the form | Text | |
| Purpose of Disclosure Option | ||
| Determining whether I am capable of managing benefits ONLY | Checkbox |
Check this box if the disclosure's sole purpose is to determine if you are capable of managing benefits.
|
| Representative's Authorization Information | ||
| 1 Parent of minor | Checkbox |
Check this box if the person signing this form is the parent of a minor whose records are being disclosed.
|
| 2 Guardian | Checkbox |
Check this box if the person signing this form is the legal guardian of the individual whose records are being disclosed.
|
| 3 Other personal representative | Checkbox |
Check this box if the person signing this form is an 'other personal representative' for the individual whose records are being disclosed.
|
| Representative's Authorization Explanation | Text |
Provide an explanation for the basis of authority if the form is signed by an other personal representative.
|
| Representative's Second Signature | Text |
Provide the second signature for the parent, guardian, or personal representative if two signatures are required by State law.
|
| Second Witness Information | ||
| Second Witness Name | Text |
Enter the full name of the second witness.
|
| Second Witness Phone Number or Address | Text |
Enter the phone number or address of the second witness.
|
| Specific Permission to Release | ||
| PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW **. This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical, educational, and other information under P.L. 104-191 ("HIPAA"); 45 C F R parts 160 and 164; 42 U.S. Code section 290 d d -2; 42 C F R part 2; 38 U.S. Code section 7 3 3 2; 38 C F R 1.4 7 5; 20 U.S. Code section 1 2 3 2 g ("F E R P Ay"); 34 C F R parts 99 and 300; and State law. 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 C F R 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 H I V/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 | Text | |
| SSA/DDS Additional Information | ||
| SSA/DDS Additional Information | Text |
Provide any additional information needed to identify the subject, the specific source, or the material to be disclosed.
|