TN 46 (10-14)

A. Instructions for obtaining Form SSA-827

1. Obtaining Form SSA-827 for initial claims and continuing disability reviews (CDRs)

Request one signed Form SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)) per case.

a. Electronically signed Form SSA-827

1. If the claim has a Certified Electronic Folder (CEF):

   • do not print, fax or scan Form SSA-827 into the CEF because the system automatically adds electronically signed forms to the CEF;

   • transfer the claim to the disability determination services (DDS) when appropriate; and

   • do not delay the claim to seek the claimant’s witnessed signature unless you know from experience that certain sources require a witnessed signature.

     NOTE: Signed forms completed online do not include a witness signature.

2. If the claim is an Electronic Disability Collect System (EDCS) exclusion:

   • do not print Form SSA-827 if an electronically signed form exists; it will print as part of the Internet Adult Disability Report (i3368);

   • file the Form SSA-827 in the blue (E) section of the paper modular disability folder (MDF); and

   • forward the case to the DDS.

     For instructions about printing an i3368 from Internet Query, see DI 81007.010.

     NOTE: If a claim is an EDCS exclusion without an associated electronic folder (EF), obtain a paper Form SSA-827 with a pen and ink signature.

b. Pen and ink signed Form SSA-827 for initial claims and CDRs

1. If the claim has a CEF:

   • fax or scan page one of the signed Form SSA-827 into the CEF with the appropriate barcode; fax or scan page two only when the claimant has written something on it (DDS legacy systems generate page two of Form SSA-827 as a stock reproduction);

   • Important: The document type used for form SSA-827 is 1050 and displays on the printed bar code page. Also, ensure that other documents are not added under the form SSA-827 barcode. verify that a legible and clear image of Form SSA-827 is in eView before transferring the claim; and

   • shred the paper Form SSA-827.

2. If the claim is an EDCS exclusion:

   • file Form SSA-827 in the blue (E) section of the paper MDF;

   • forward the case to the DDS; and

   • if there is an EF attached to an EDCS exclusion, then fax or scan Form SSA-827 into the EF.

2. Obtaining Form SSA-827 for reconsideration level appeals

Obtain a newly signed and dated Form SSA-827 before sending an appeal to the DDS, even if the date on the Form SSA-827 in file is within the past 12 months.

NOTE: If the claimant fails to provide a newly signed and dated SSA-827, please review DI 12005.005.D for further instructions.

a. Electronically signed Form SSA-827 for reconsideration level appeals

1. If the appeal has a CEF:

   • transfer the appeal to the DDS when appropriate;

   • do not print, fax or scan the form into the CEF because the system automatically adds the electronically signed Form SSA-827 to the CEF; and

   • do not delay the appeal to seek the claimant’s witnessed signature, unless you know from experience that certain sources require a witnessed signature.

     NOTE: A signed Form SSA-827 submitted online does not include a witness signature.

2. If the appeal is an EDCS exclusion:

   • do not print Form SSA-827 if an electronically signed form exists; it will print as part of the Disability Report--Appeals (i3441);

   • file Form SSA-827 in the blue (E) section of the paper MDF; and

   • forward the appeal to the DDS.

     For instructions about printing an i3441 from Internet Query, see DI 81007.010.

     NOTE: If there is an EF associated with an EDCS exclusion, you may use the attestation process. Otherwise, obtain a paper Form SSA-827 with a pen and ink signature, and follow the instructions in this section.

b. Pen and Ink signed Form SSA-827 for reconsideration level appeals

1. If the appeal has a CEF:

   • fax or scan page one of Form SSA-827 into the CEF with the appropriate barcode; fax or scan page two only when the claimant has written something on it;

   • IMPORTANT: The document type used for Form SSA-827 is 1050 and displays on the printed bar code page. Also, ensure that other documents are not added under the Form SSA-827 barcode. verify that a legible and clear image of Form SSA-827 is in eView before transferring the appeal; and

   • shred the paper Form SSA-827.

2. If the appeal is an EDCS exclusion:

   • file Form SSA-827 in the blue (E) section of the paper MDF;

   • forward the appeal to the DDS; and

   • if there is an EF attached to an EDCS exclusion, then fax or scan Form SSA-827 into the EF.

3. Obtaining Form SSA-827 for Administrative Law Judge (ALJ) level appeals

Request one newly signed and dated Form SSA-827 per case.

You may transfer the ALJ level appeal request without a Form SSA-827. No follow-up attempts are required. Do not delay the appeal request to obtain a newly signed and dated Form SSA-827 (or witness signature(s)).

a. Electronically signed Form SSA-827 for ALJ level appeals

1. If the appeal has a CEF:

   • transfer the appeal to the adjudicating component when appropriate;

   • do not print, fax or scan the form into the CEF because the system automatically adds an electronically signed Form SSA-827 to the CEF. A signed Form SSA-827 submitted online does not include a witness signature;

   • do not delay the appeal to seek the claimant’s witnessed signature unless you know from experience that certain sources require a witnessed signature.

2. If the appeal is an EDCS exclusion:

   • do not print Form SSA-827 if an electronically signed form exists because it will print as part of the i3441;

   • file Form SSA-827 in the blue (E) section of the paper MDF; and

   • forward the appeal to the adjudicating component with the SSA-636 (Transmittal Notice – Hearing Case).

For instructions about printing an i3441 from Internet Query, see DI 81007.010.

NOTE: If there is an electronic folder associated with an EDCS exclusion, you may use the attestation process. Otherwise, obtain a paper Form SSA-827 with a pen and ink signature, and follow the instructions in this section.

b. Pen and Ink signed Form SSA-827 for ALJ level appeals

1. If the appeal has a CEF:

   • fax or scan both pages of Form SSA-827 into the CEF with the appropriate barcode;

   • Important: The document type used for Form SSA-827 is 1050 and displays on the printed bar code page. Also, ensure that other documents are not added under the Form SSA-827 barcode.

   • verify a legible image of Form SSA-827 is in eView before transferring the appeal; and

   • shred the paper Form SSA-827.

2. If the appeal is an EDCS exclusion:

   • file Form SSA-827 in the blue (E) section of the paper MDF;

   • forward the appeal to the adjudicating component with the SSA-636 routing slip; and

   • if there is an EF associated with an EDCS exclusion, then fax or scan Form SSA-827 into the EF.

4. Form SSA-827 received after the claim is transferred

If the field office receives a pen and ink signed Form SSA-827 after transferring jurisdiction of the claim, do one of the following:

1. If the claim has a CEF:

   • fax or scan Form SSA-827 into the CEF with the appropriate barcode;

   • verify a legible image of Form SSA-827 is in eView; and

   • shred the paper Form SSA-827.

2. If the claim is an EDCS exclusion, mail the Form SSA-827 to the adjudicating component for association with the paper folder.

REMINDER:

• For the DDS, fax or scan page two of Form SSA-827 into the CEF only if the claimant has written something on it.

• For the hearing office, fax or scan pages one and two of Form SSA-827 into the CEF.

B. Disability Starter Kits

While we do not have a requirement to send Disability Starter Kits to every claimant, we recommend sending the claimant a Form SSA-827 with the starter kit in advance of a disability teleclaim to:

• eliminate the time involved in obtaining a pen and ink signed Form SSA-827, and

• provide a copy of the form for the claimant to review when the attestation process is an option.

1. Recommended procedures

If you send Form SSA-827 to the claimant with either the SSA-1170-KIT (Adult Disability Starter Kit) or the SSA-1171-KIT (Childhood Disability Starter Kit), take the following steps:

1. Enclose one Form SSA-827;

2. Request only one completed Form SSA-827, unless the local DDS has made other arrangements to obtain additional forms; and

3. Enclose a return envelope. (For cases involving title XVI claims, enclose a postage-paid envelope.)

2. Suggested language

Include one of the following explanations in the return envelope supplied with the starter kit (or follow state-specific release requirements if modifying the explanations):

a. Explanation for the Adult Disability Starter Kit

“We request the following documents to process your claim for benefits. The sooner we receive the documents, the sooner we can process your application. If you would like us to help get your medical reports, please sign and date Form SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)). Have someone else sign in the space marked “witness.” Include your complete mailing address. Return Form SSA-827 in the enclosed envelope.”

b. Explanation for the Childhood Disability Starter Kit

1. If state law does not require the signature of a child for disclosure of medical records, use the following language:

“We request the following documents to process your claim for benefits. The sooner we receive the documents, the sooner we can process your application. If you would like us to help get your medical reports, a parent or guardian should sign and date Form SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)) in the appropriate spaces. Have someone else sign in the space marked “witness.” Include your complete mailing address. Return Form SSA-827 in the enclosed envelope.”

NOTE: If an individual chooses to sign Form SSA-827 using the attestation process during the teleclaim, employees should advise the individual not to sign and return the paper form.

2. If state law requires both the signature of the child and his or her parent or guardian for disclosure of medical records, use the following language:

“We request the following documents to process your claim for benefits. The sooner we receive the documents, the sooner we can process your application. If you would like us to help get your medical reports, please sign and date Form SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)). Have someone else sign in the space marked “witness.” Include your complete mailing address. If the claim is for a child, both the child and a parent or guardian should sign Form SSA-827 in the appropriate spaces. Return Form SSA-827 in the enclosed envelope.”

C. References

• DI 70005.005 Overview of the Paper Modular Disability Folder (MDF)

• DI 81010.030 Certified Electronic Folder (CEF) Exclusions and Limitations