Form SSA-827, Authorization to Disclose Information Instructions

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This form contains 26 fields organized into 8 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Authority to Sign (If Not Signed by Subject) - Role and Explanation
Parent of minor Checkbox
Check this box if you are signing the form on behalf of the subject because you are the parent of a minor.
Guardian Checkbox
Check this box if you are signing the form on behalf of the subject because you are the subject’s legal guardian.
Other personal representative (explain) Checkbox
Check this box if you are signing the form on behalf of the subject as another type of authorized personal representative and you will provide an explanation of your authority.
Authority to Sign Explanation Text
Provide an explanation of your legal authority or basis for signing this form on behalf of the subject of disclosure. Fill only if 'Other personal representative (explain)' is 'Yes'.
Depends on: Other personal representative (explain)
Explanation of Form SSA-827, "Authorization to Disclose Information to the Social Security Administration (SSA)"
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
This section provides a detailed explanation of the SSA-827 form, including the legal provisions and requirements for disclosing medical, educational, and other personal information to the SSA.
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
This section provides a detailed explanation of the Privacy Act Statement, including the collection and use of personal information, the legal basis for the collection, the voluntary nature of providing the information, and the potential consequences of not providing it. It also outlines the routine uses of the information and where additional information can be found.
Individual Authorizing Disclosure - Signature and Contact Info
Individual Signature Text
Enter the signature of the individual authorizing disclosure of records.
Date Signed Date
Enter the date the individual signed this authorization.
Street Address Text
Enter the individual’s street address.
Phone Number Text
Enter the individual’s phone number including area code.
City Text
Enter the city for the individual’s mailing address.
State Text
Enter the state for the individual’s mailing address.
ZIP Code Text
Enter the ZIP code for the individual’s mailing address.
OF WHAT
Other Records or Information to Disclose Text
Enter any additional records or information you want included in what may be disclosed, beyond what is already listed in this section.
SSA/DDS Notes (Source/Material Details) Text
Provide any additional information needed to identify the subject, the specific source, or the material to be disclosed.
Determining whether I am capable of managing benefits ONLY Checkbox
Check this box only if the purpose of this authorization is limited to determining whether you are capable of managing your benefits.
Paperwork Reduction Act Statement
Statement Reference Number Text
Enter the reference number associated with the Paperwork Reduction Act Statement section.
Page Number Text
Enter the page number for this page of the form.
Parent/Guardian/Representative Second Signature (If Required)
Parent/Guardian/Representative Signature Text
Enter the parent, guardian, or authorized personal representative’s signature if a second signature is required. Fill only if 'Parent of minor', 'Guardian', 'Other personal representative (explain)' is 'Yes' (any).
Depends on: Parent of minor, Guardian, Other personal representative (explain)
Whose Records to be Disclosed
Person’s Name Text
Enter the full name (first, middle, last, and any suffix) of the person whose records are to be disclosed.
Social Security Number (SSN) Text
Enter the Social Security number of the person whose records are to be disclosed.
Date of Birth Date
Enter the date of birth of the person whose records are to be disclosed.
WITNESS
Witness Signature Text
Enter the signature of the witness who knows the person signing the form or is satisfied of the person’s identity.
Witness Phone Number or Address Text
Enter the witness’s phone number or address.
Second Witness Signature Text
Enter the signature of a second witness, if a second witness is needed. Fill only if 'Signature' is 'X'.
Depends on: Individual Signature
Second Witness Phone Number or Address Text
Enter the second witness’s phone number or address. Fill only if 'Second Witness Signature' is filled (any).
Depends on: Second Witness Signature