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Form SSA-3288 (07-2013) EF (07-2013) Destroy Prior Editions
Social Security Administration
Consent for Release of Information
OMB No. 0960-0566
Instructions for Using this Form
Complete this form only if you want us to give information or records about you, a minor, or a legally incompetent adult, to an
individual or group (for example, a doctor or an insurance company). If you are the natural or adoptive parent or legal guardian,
acting on behalf of a minor child, you may complete this form to release only the minor's non-medical records. We may charge a
fee for providing information unrelated to the administration of a program under the Social Security Act.
NOTE: Do not use this form to:
• Request the release of medical records on behalf of a minor child. Instead, visit your local Social Security office or call our toll-
free number, 1-800-772-1213 (TTY-1-800-325-0778), or
• Request detailed information about your earnings or employment history. Instead, complete and mail form SSA-7050-F4. You
can obtain form SSA-7050-F4 from your local Social Security office or online at www.ssa.gov/online/ssa-7050.pdf.
How to Complete this Form
We will not honor this form unless all required fields are completed. An asterisk (*) indicates a required field. Also, we will not
honor blanket requests for "any and all records" or the "entire file." You must specify the information you are requesting and you
must sign and date this form. We may charge a fee to release information for non-program purposes.
• Fill in your name, date of birth, and social security number or the name, date of birth, and social security number of the person
to whom the requested information pertains.
• Fill in the name and address of the person or organization where you want us to send the requested information.
• Specify the reason you want us to release the information.
• Check the box next to the type(s) of information you want us to release including the date ranges, where applicable.
• You, the par