Form SSA-827, Authorization to Disclose Information Instructions
This form contains 26 fields organized into 10 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Authorization | ||
| TO WHOM. 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. [Also, for international claims, to the U.S. Department of State Foreign Service Post.]. PURPOSE. Determining my eligibility for benefits, including looking at the combined effect of any impairments that by themselves would not meet SSA's definition of disability; and whether I can manage such benefits. Determining whether I am capable of managing benefits ONLY (check only if this applies) | CheckBox |
Check this box if you are authorizing the SSA to determine whether you are capable of managing benefits.
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| EXPIRES WHEN. This authorization is good for 12 months from the date signed (below my signature). • I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above. • I understand that there are some circumstances in which this information may be re disclosed to other parties (see page 2 for details). • I may write to SSA and my sources to revoke this authorization at any time (see page 2 for details). • SSA will give me a copy of this form if I ask; I may ask the source to allow me to inspect or get a copy of material to be disclosed. • I have read both pages of this form and agree to the disclosures above from the types of sources listed. PLEASE SIGN USING BLUE OR BLACK INK ONLY INDIVIDUAL authorizing disclosure. Signature. Ay Wet Signature is required. Complete the form, print and sign | Text |
Provide your signature here to authorize the disclosure of your information. Use blue or black ink only.
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| IF not signed by subject of disclosure, specify basis for authority to sign. Parent of minor | CheckBox |
Check this box if you are a parent of a minor and are signing on their behalf.
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| Guardian | CheckBox |
Check this box if you are a guardian signing on behalf of the individual.
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| Other personal representative | CheckBox |
Check this box if you are another type of personal representative signing on behalf of the individual.
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| If other personal representative is checked explain | Text |
If you checked 'Other personal representative', explain your relationship to the individual here.
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| (Parent/guardian/personal representative sign here if two signatures required by State law). Ay Wet Signature is required. Complete the form, print and sign | Text |
If required by State law, a parent, guardian, or personal representative should sign here. Use blue or black ink only.
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| Date Signed | Text |
Enter the date when the form is signed.
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| Contact Information | ||
| Street Address | Text |
Enter your street address.
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| Phone Number (with area code) | Text |
Enter your phone number, including the area code.
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| City | Text |
Enter the city where you reside.
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| Disclosure Information | ||
| FROM WHOM. • All medical sources (hospitals, clinics, labs, physicians, psychologists, etc.) including mental health, correctional, addiction treatment, and V Ay 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). THIS BOX TO BE COMPLETED BY SSA/D D S (as needed). Additional information to identify the subject (e.g., other names used), the specific source, or the material to be disclosed | Text |
This section lists the sources from which information may be disclosed, including medical sources, educational sources, social workers, employers, and others. This box is to be completed by SSA/DDS as needed.
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| Form Explanation | ||
| 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.
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| Instructions | ||
| 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 |
Read the entire form carefully before signing. This section outlines the types of records and information that will be disclosed, including medical, educational, and other personal information.
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| Navigation | ||
| 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 |
This field indicates that you have reached the end of the form. If you tab out of this field, you will return to the beginning of the form.
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| Paperwork Reduction Act Statement | ||
| 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 |
This section explains the Paperwork Reduction Act Statement, including the legal requirements for information collection, the estimated time to complete the form, and where to send the completed form. It also provides contact information for the Social Security Administration and instructions for submitting comments regarding the burden estimate.
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| Personal Information | ||
| Form SSA-827 (06-2024). Discontinue Prior Editions. Social Security Administration. AUTHORIZATION TO DISCLOSE INFORMATION TO THE SOCIAL SECURITY ADMINISTRATION (SSA). Page 1 of 2. O M B Number 0960-0623. Whose Records to be Disclosed. NAME (First, Middle, Last, Suffix) | Text |
Enter the full name of the individual whose records are to be disclosed, including first name, middle name, last name, and any suffix.
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| S S N | Text |
Enter the Social Security Number (SSN) of the individual whose records are to be disclosed.
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| Birthday (M M/D D/Y Y Y Y) | Text |
Enter the birthdate of the individual whose records are to be disclosed in the format MM/DD/YYYY.
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| State | Text |
Enter the state where you currently reside.
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| ZIP | Text |
Enter your ZIP code.
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| Privacy Act Statement | ||
| 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.
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| Witness Information | ||
| Witness. I know the person signing this form or am satisfied of this person's identity: Signature. Ay Wet Signature is required. Complete the form, print and sign | Text |
Signature of the witness who knows the person signing this form or is satisfied with the person's identity. A wet signature is required. Complete the form, print, and sign.
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| Phone Number (or Address) | Text |
Enter the phone number or address of the first witness.
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| IF needed, second witness sign here (e.g., if signed with "X" above). Ay Wet Signature is required. Complete the form, print and sign | Text |
Signature of the second witness if needed (e.g., if the form was signed with an 'X'). A wet signature is required. Complete the form, print, and sign.
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| Phone Number (or Address) | Text |
Enter the phone number or address of the second witness.
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