TN 46 (10-14)

Citations:

P.L. 104-191 the Health Insurance Portability and Accountability Act of 1996 (HIPAA);

45 CFR parts 160 and 164;

42 U.S.C. section 290dd-2;

42 CFR part 2;

38 U.S.C. section 7332;

38 CFR 1.475;

20 U.S.C. section 1232g the Family Education Rights and Privacy Act (FERPA);

34 CFR parts 99 and300; and State law.

The Form SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)) is the form we use to obtain medical and non-medical information required to:

• process claims and continuing disability reviews, and

• determine the claimant’s capability of managing benefits.

NOTE: The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule permits disclosure of all medical records; the Privacy Act protects the information SSA collects.

Only claimants residing in Puerto Rico may use Form SSA-827-SP, the Spanish version of the form. To view or print Form SSA-827, see OS 15020.110. To view or print Spanish language instruction for completing the SSA-827, see the SSA-827–SP-INST

A. Purpose of Form SSA-827

The completed Form SSA-827 serves two purposes in disability claims (and non-disability claims when capability is an issue):

1. The form serves as the claimant’s written request to a medical source or other source to release information. These sources include, but are not limited to, the claimant’s:

   • doctors,

   • hospitals,

   • schools,

   • nurses,

   • social workers,

   • friends,

   • employers, and

   • family members.

2. The form serves as authorization for the claimant’s sources to release information to SSA.

Additional details on the purpose of Form SSA-827 are on page 2 of the form. SSA and the disability determination services (DDS) send the completed Form SSA-827 to sources, including consultative examination sources, with requests for evidence (unless other local arrangements apply).

Foreign field offices (FOs) usually obtain a completed Form SSA-827 for U.S. medical sources only. You can find instructions for obtaining evidence from foreign sources in the international agreements.

B. Procedures for completing Form SSA-827

The following procedures apply to completing Form SSA-827. However, regional instructions for completion may vary due to states’ release requirements. Regional offices (ROs) may provide specific guidance for completing Form SSA-827.

1. WHOSE records to be disclosed box

The claimant or SSA completes the “WHOSE Records to be Disclosed” box located in the upper right-hand corner of the form.

2. OF WHAT section

The OF WHAT section describes the types of information sources can disclose, including the claimant’s medical records, educational records, and other information related to the claimant’s ability to perform tasks. Form SSA-827 includes specific permission to release the following:

1. All records and other information regarding the claimant’s treatment, hospitalization, and outpatient care including, and not limited to:

   • sickle cell anemia;

   • gene-related impairments (including genetic test results);

   • drug abuse, alcoholism, or other substance abuse;

   • psychological, psychiatric, or other mental impairment(s) (excludes “psychotherapy notes” as defined in 45 CFR 164.501);

   • records that may indicate the presence of a communicable or noncommunicable disease; and

   • tests for or records of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS).

2. Information about how the impairment(s) affects the claimant’s ability to work, complete tasks, and perform activities of daily living;

3. Copies of educational tests or evaluations, including individualized educational programs, triennial assessments, psychological and speech evaluations, teachers’ observations, and any other records that can help evaluate function; and,

4. Information created before the claimant signs the authorization and information created within 12 months after the authorization’s signature date.

Every Form SSA-827 includes specific permission to release all records to avoid delays in processing. Using the form does not imply that the claimant has received treatment for drug abuse, alcoholism, sickle cell anemia, HIV/AIDS, or any other communicable or noncommunicable disease.

If State law requires the claimant to affirm his or her informed consent by initialing the white spaces to the left of each category of this section, the claimant must use a paper Form SSA-827 with a pen and ink signature.

3. FROM WHOM section

The FROM WHOM section contains potential sources of information including, but not limited to, the following:

• consulting examiners used by SSA;

• social workers and rehabilitation counselors;

• employers, insurance companies, workers’ compensation programs;

• all educational sources, such as schools, teachers, records administrators, and counselors;

• all medical sources (such as hospitals, clinics, labs, physicians, and psychologists) including mental health, correctional, addiction treatment, and Department of Veterans Affairs (VA) health care facilities; and

• others who may know about the claimant’s condition, such as family, neighbors, friends, and public officials.

4. FROM WHOM box

The FROM WHOM section contains an area labeled, “THIS BOX TO BE COMPLETED BY SSA or DDS (as needed).”

a. Entering specific information in the FROM WHOM box

SSA or DDS may use this area, as needed, to:

• list specific information about the authorization (for example, the name of a source the claimant does or does not want SSA to contact);

• record specific information about a source when the source refuses to accept a general release authorization (for example, the name of the source, dates, and type of treatment); and

• provide additional identification of the claimant (for example, maiden name, alias, or the mother’s name for a newborn child’s claim).

b. Claimant restricts Form SSA-827

When a claimant requests to restrict Form SSA-827, follow these steps:

1. Ensure that the claimant understands the form’s purpose (refer to the first paragraph on page 2 of Form SSA-827).

2. If the claimant objects to any part of the authorization and refuses to sign the form, line through the offending words and have the claimant initial the deletion.

   IMPORTANT: Do not use the eAuthorization signature process if the claimant requests to write anything other than a signature on the form. In that case, have the claimant pen and ink sign a paper form.

3. If the claimant requests to restrict the disclosure of information, enter the restriction in the box labeled, “THIS BOX TO BE COMPLETED BY SSA or DDS (as needed).” For example, “Do not contact Dr. X.” Leave enough room in the box for the DDS to record information about a source, should the need arise.

4. Mark the checkbox on the Electronic Disability Collect System (EDCS) transfer screen or on the eView Edit Document Information screen if the claimant modified Form SSA-827 or if access to information is restricted. The checkbox alerts the DDS when Form SSA-827 contains restrictive language.

   EXCLUSION: If there is no EDCS case, annotate the “Remarks” space on the paper Form SSA-3367 (or use a Form SSA-5002 (Report of Contact)).

   Sometimes claimants or appointed representatives add restrictive language regarding the use of records by the Cooperative Disability Investigation Unit (CDIU) (for example, “Not for use by CDIU”). However, adding restrictive language does not prevent the DDS from completing required claims development or furnishing such records to the CDIU. The CDIU, which is part of the Office of the Inspector General organizational structure, is entitled to these records under the Inspector General Act and SSA regulations.

   NOTE: When a source refuses to release information to the DDS or CDIU because of the “Not for use in the CDIU” or similar annotation on Form SSA-827, the DDS:

   • advises the claimant that failure to provide an unrestricted Form SSA-827 could prevent us from developing the evidence necessary to process the claim;

   • informs the claimant that the CDIU has access to the records regardless of the restrictive language; and

   • attempts to obtain an unrestricted Form SSA-827.

5. TO WHOM section

The TO WHOM section informs the claimant about the state and federal entities that process the disability claim: the Social Security Administration and the state agency authorized to process the claim (usually the DDS), including contract copy services, doctors, or other professionals consulted during the process. In addition, for international claims, the U.S. Department of State Foreign Service Post is involved.

6. PURPOSE section for non-disability capability claims

Authorization for the general release of “all records” is still necessary for non-disability claims where the claimant’s capability is an issue. For these claims, in the PURPOSE section, check the box before the statement, “Determining whether I am capable of managing benefits ONLY.” (For procedures on developing capability, see GN 00502.020 and GN 00502.050A.)

7. EXPIRES WHEN section

The authorization expires 12 months after the date below the signature of the person authorizing disclosure. For further details about disclosing information, re-disclosing information, and revoking the authorization, see page 2 of Form SSA-827.

By signing Form SSA-827:

• the claimant authorizes the use of a copy (including an electronic copy) of this form for the disclosure of the information;

• the claimant understands there are circumstances in which we may re-disclose this information to other parties (see page 2 of Form SSA-827 for details);

• the claimant may write to SSA and sources to revoke this authorization at any time (see page 2 of Form SSA-827 for details);

• SSA will supply a copy of this form if the claimant asks. The claimant may ask the source to allow inspection (or to get a copy) of the material to be disclosed; and

• the claimant indicates he or she read both pages of Form SSA-827 and agrees to disclosures from the types of sources listed.

IMPORTANT: Form SSA-827 must include the claimant’s signature and date of signing. Never instruct claimants to provide an undated Form SSA-827. If the claimant submits an undated Form SSA-827, return it to the claimant for dating.

8. INDIVIDUAL authorizing disclosure box

Have the claimant sign, date, and complete the INDIVIDUAL authorizing disclosure box at the bottom left of Form SSA-827.

For more information about signature requirements for Form SSA-827 or for completing this section when the claimant is not signing on his or her own behalf, see DI 11005.056.

9. IF not signed by subject of disclosure box

If the claimant has not signed Form SSA-827, make sure the appropriate checkbox is marked to indicate that a parent of a minor, a guardian, or other personal representative signed the form. If a personal representative signed the form, explain the relationship to the claimant in the space provided under the checkbox.

10. WITNESS box

We provided a block in this section for the witness signature, address, and phone number. We provided a second block, to the right of the first block, for the signature of a second witness, if required.

When we attest to the claimant’s signature on Form SSA-827, we document the attestation in the witness box see DI 11005.056.

If the claimant signs by mark, the witness signature is required and the witness block must be completed.

IMPORTANT: If the field office (FO) receives a non-attested Form SSA-827 without the signature of a witness, we continue to process the claim. Do not delay the claim to seek the claimant's witnessed signature unless the claimant signed Form SSA-827 by mark or the FO knows from experience that certain sources require a witnessed signature.