• Form SSA-827 (06-2024) UF Discontinue Prior Editions

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  • AUTHORIZATION TO DISCLOSE INFORMATION TO THE SOCIAL SECURITY ADMINISTRATION (SSA)

  • ** PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW

  • I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange): 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 noncommunicable disease; and tests for or records of HIV/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. THIS BOX TO BE COMPLETED BY SSA/DDS (as needed Additional information to identify All medical sources (hospitals, clinics, labs, the subject (e.g., other names used), the specific source, or the material to be disclosed: 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, insurance companies, workers' compensation programs Others who may know about my condition (family, neighbors, friends, public officials)

  • 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.] 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)

    EXPIRES WHEN This authorization is good for 12 months from the date signed (below my signature Iauthorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above. Iunderstand that there are some circumstances in which this information may be redisclosed to other parties (see page 2 for details Imay 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

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