Release Forms > General Consent to Release Information Form


General Consent to Release Information Form

General Consent to Release Information Form

The general consent to release information form is a document that is provided by the Social Security Administration for the purpose of obtaining information from thirds parties (ie: Doctors, Psychologists, Psychiatrist or any other party who may have information pertaining to the applicant.

If the person authorizing release of information on behalf of a minor, they must be the natural or adoptive parent or legal guardian, acting on behalf of the minor child, for release the minor’s non-medical records only. The completed form is only acceptable if the person authorizing the information release on behalf of  a minor, or a legally incompetent adult, to an individual or group (ie:, a physician or an insurance company).

Once the form is completed, it must be taken in person to a local Social Security Office. Locations may be found online at www.socialsecurity,gov or will be listed under U.S Government Agencies in any local telephone directory. All fields must be completed or the Social Security Administration will not honor the applicant’s request. Fees may apply.

 

How to Write

Step 1 – Download in Adobe PDF (.pdf).

Step 2 -Consent for Release of Information Form

  • Once the document has been downloaded, take the time to read through the first page of the document to ensure a clear understanding of what is expected and what the agency may provide for the applicant.

Step 3 – Applicant’s Information – All required fields are marked with an asterisk * – Complete the following:

  • Applicant’s Full Name
  • Applicant’s Date of Birth in mm/dd/yyyy format
  • Social Security Number in 000-00-0000 format

Step 4 – Authorization – Enter the following information with regard to whom information shall be released:

  • Name(s) of Person(s) or Organization(s)
  • Complete Addresses(s) of Person(s) or Organization(s)
  • Enter the reason for which the applicant would like to have the information released (some fees may apply depending upon the request)

Step 5 – Request for Release of Specific Information –

  • No request for “any and all” or “my entire life” will be honored or if the date ranges are not entered. Select from the boxes provided. Check only those records needed and enter the date ranges if lines are presented for entry of dates
  • Specify the requested records on the lines provided if there will be other records other than those boxes selected (ie:  doctor report, application, determination or questionnaire)

Step 6 – Signatures – IF the applicant’s name is signed only by an “X” two witnesses will be required:

  • Applicant must read the bolded statement
  • If the applicant or the person working on their behalf understands and agrees to the statement enter:
  • Applicant’s signature or “X”
  • Date of Signature in mm/dd/yyyy format
  • Applicant’s complete address
  • Relationship to applicant
  • Daytime telephone number
  • AND
  • If the applicant’s signature is an “X”; two witnesses must witness the applicant’s signature and provide:
  • Witnesses Signatures Respectively
  • Each witnesses address(Number,street,City,State, and Zip Code)

Make copy(s) of this document for the applicant’s as well as the caregiver (if any) records