SSA-3288

Consent For Release Of Information

Download and Print the SSA-3288

Instructions for Using this Form
Complete this form only if you want us to give information or records about you, a minor, or a legally incompetent adult, to an individual or group (for example, a doctor or an insurance company). If you are the natural or adoptive parent or legal guardian, acting on behalf of a minor, you may complete this form to release only the minor's non-medical records. If you are requesting information for a purpose not directly related to the administration of any program under the Social Security Act, a fee may be charged.
NOTE: Do not use this form to:
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Request us to release the medical records of a minor. Instead, contact your local office by calling 1-800-772-1213 (TTY-1-800-325-0778), or
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Request information about your earnings or employment history. Instead, complete form SSA-7050-F4 at any Social Security office or online at www.ssa.gov/online/ssa-7050.pdf.
How to Complete this Form
We will not honor this form unless all required fields are completed. An asterisk (*) indicates a required field. Also, we will not honor blanket requests for "all records" or the "entire file." You must specify the information you are requesting and you must sign and date this form.
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Fill in your name, date of birth, and social security number or the name, date of birth, and social security number of the person to whom the information applies.
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Fill in the name and address of the individual (or organization) to whom you want us to release your information.
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Indicate the reason you are requesting us to disclose the information.
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Check the box(es) next to the type(s) of information you want us to release including the date ranges, if applicable.
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You, the parent or legal guardian acting on behalf of a minor, or the legal guardian of a legally incompetent adult, must sign and date this form and provide a daytime phone number where you can be reached.
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If you are not the person whose information is requested, state your relationship to that person. We may require proof of relationship.

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