SSA-827

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

Download and Print the SSA-827

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

WHOSE Records to be Disclosed - NAME (First, Middle, Last) - SSN - Birthday (mm/dd/yy)

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 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.

And much more...