I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange): of 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 CFR 164.501)
 --   Drug abuse, alcoholism, or other substance abuse

 --   Sickle cell anemia

 --   Records which may indicate the presence of a communicable or venereal disease which may include, but are not limited to, diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS); and tests for HIV.

 --  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.

FROM WHOM
·       All medical sources (hospitals, clinics, labs, physicians, psychologists, etc.) including mental health, correctional, addiction treatment, and VA health care facilities

·       All educational sources (schools, teachers, records administrators, counselors, etc.)

·       Social Workers/rehabilitation counselors

·       Consulting examiners used by SSA

·       Employers

·       Others who may know about my condition (family, neighbors, friends, public officials)

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.)