OMB No. 0960-0566
Social Security Administration
Consent for Release of Information
Please read these instructions carefully before completing this form.
When to Use
Complete this form only if you want the Social Security Administration to give
information or records about you to an individual or group (for example, a doctor
or an insurance company).
Natural or adoptive parents or a legal guardian, acting on behalf of a minor, who
want us to release the minor's:
· nonmedical records, should use this form.
· medical records, should not use this form, but should contact us.
Note: Do not use this form to request information about your earnings or employment
history. To do this, complete Form SSA-7050-F4. You can get this form at any
Social Security office.
This consent form must be completed and signed only by:
the person to whom the information or record applies, or
the parent or legal guardian of a minor to whom the
nonmedical information applies, or
the legal guardian of a legally incompetent adult to whom the
To complete this form:
· Fill in the name, date of birth, and Social Security Number of the person to whom
the information applies.
· Fill in the name and address of the individual or group to which we will send the
· Fill in the reason you are requesting the information.
· Check the type(s) of information you want us to release.
· Sign and date the form. If you are not the person whose record
we will release,
please state your relationship to that person.
PAPERWORK REDUCTION ACT STATEMENT: This information collection meets the clearance requirements
of 44 U.S.C. §3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer
these questions unless we display a valid Office of Management and Budget control number. We estimate that it
will take about 3 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING