Social Security Administration

 Please read these instructions carefully before completing this form.

 When To Use       Complete this form only if you want the Social Security

This Form             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:

 

·     non-medical 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-F3.  You can get this form at any Social

          Security office.

 

How To               This consent form must be completed and signed only by:

Complete

This Form             ·   the person to whom the information or record applies, or

                            ·   the parent or legal guardian of a minor to whom the

                                 non-medical information applies, or

                            ·   the legal guardian of a legally incompetent adult to whom

                                 the information applies.

 

                            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 information.

                            ·   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.

 

Note from Region 7 RCEP: In order to receive benefit information in a useable and understandable format, attach the “Information Release Form” distributed by RCEP7-University of MO to the SSA 3288. This form has been designed and arranged in a way to give Benefit Specialists and/or SSA beneficiaries the information in a non SSA coded format.   Have the individual and his or her guardian/payee sign both the SSA 3288 and the RCEP7 distributed form before submitting to SSA.

 

 

Social Security Administration

 

TO:   Social Security Administration

 

_____________________________  __________   ______________________________

                        Name                           Date of Birth                 Social Security Number

I authorize the Social Security Administration to release information or records
about me to:

 

                    NAME                                                 ADDRESS

_______________________  ________________________________________________

_______________________  ________________________________________________

_______________________  ________________________________________________

_______________________  ________________________________________________

 

I want this information released because:

 

I need to have accurate and current information about my benefits so I can make an informed choice about work.

 (There may be a charge for releasing information.)

 

Please release the following information:

 

___    Social Security Number

___    Identifying information (includes date and place of birth, parents’ names)

___    Monthly Social Security benefit amount

___    Monthly Supplemental Security Income payment amount

___    Information about benefits/payments I received from _______ to _______

___    Information about my Medicare claim/coverage from _______ to _______

          (specify)  __________________________________________________________

___    Medical records

___    Record(s) from my file (specify)________________________________________

__    Other (specify) Please complete the attached “Information Release Form” with the specific information requested on that form.

I am the individual to whom the information/record applies or that person’s

parent (if a minor) or legal guardian.  I know that if I make any representation

which I know is false to obtain information from Social Security records, I could

be punished by a fine or imprisonment or both.

 

Signature:_______________________________________________

(Show signatures, names, and addresses of two people if signed by mark.)

 

Date:__________ Expiration Date of Release:       Relationship:____________

This release is good for the specified period of time not to exceed 12 months from the above date.

 

modified  from SE Works ·  Dennis Born

I, __________________, hereby request the release of the following information including IRS tax information included on the SEQY to the person(s) named below. The information will be used solely for the development of a rehabilitation plan to assist me in achieving employment and accessing the Social Security work incentive programs. I understand that any false representation to knowingly and willfully obtaining information from SSA records is punishable by a fine and/or imprisonment.

 

Claimant Name:                                                                  Social Security No.                      

Representative Payee:                                                               Phone:                                    

Please send the requested information to:

 

Name:                                                                                                Phone:                                                

Address:                                                                                                                                          

    ^{Street                                                            City                                 State                                         ZIP}

 

	Yes	No	Amount
Does the claimant receive Title II benefits?
Is the claimant in overpayment status?
Does the claimant have Medicare coverage?			Part A Part B Both
How many Trial Work Period months have been used?
Does the Master Beneficiary Record (MBR) reflect any use of Trial Work Months? If so, please indicate the month and year of each TWP month used on the chart shown:	TWP MM/YY 1:                TWP MM/YY 6:                          TWP MM/YY 2:           TWP MM/YY 7:   TWP MM/YY 3:           TWP MM/YY 8:   TWP MM/YY 4:            TWP MM/YY 9:   TWP MM/YY 5:        Cessation mm/yy________
Are there any earnings posted to the SEQY after the individual’s date of entitlement? If YES, please attach a copy of the SEQY.
When was the last Continuing Disability Review? (mm/yy)            When is the next CDR? (mm/yy)
Disability on Record:
SSA Representative Completing Title II Info:
	Yes	No	Amount
Does the claimant receive Title XVI/SSI benefits?
Is the claimant in overpayment status?
Is the claimant in 1619(b) status?
Does the claimant’s SSID show current earned income? If YES, please attach a copy of the wages posted.
Does the claimant’s SSID indicate any IRWEs?
Does the claimant’s SSID show previous or current PASS?
Does the claimant’s record indicate BWE?

SSA Representative Completing Title XVI Info:                                                                      

Claimant’s Signature:                                           Date:                          Expiration Date:    

Representative Payee’s Signature:                                                                  Date:             

 

Ticket to Work and Work Incentive Improvement Act of 1999

The President signed the Ticket to Work and Work Improvement Act of 1999 on December 17, 1999.  This new law:

·        Increases beneficiary choice in obtaining rehabilitation and vocational service;

·        Removes barriers that require people with disabilities to choose between health care coverage and work; and

·        Assures that more Americans with disabilities have the opportunity to participate in the workforce and lessen their dependence on public benefits.

 

The provisions of the law become effective at various times, generally beginning one year after enactment.  They are described below.

 

Establishment of the Ticket to Work and Self-Sufficiency Program

·        The program will be phased in nationally over a three-year period beginning January 1, 2001, with the first Tickets issued early in 2001.

·        Social Security and Supplemental Security Income disability beneficiaries will receive a “Ticket” they may use to obtain vocational rehabilitation (VR), employment or other support services from an approved provider of their choice.

·        The Ticket program is voluntary.

 

Expanded Availability of Health Care Services

The law includes several enhancements to Medicaid and Medicare that are effective October 1, 2000.

·             Creates grants for infrastructure development helping with the administrative costs of planning for and developing personal Assistance services available under Medicaid to the extent to allow individuals with disabilities to work in the competitive job market.

·             States will have the option to provide Medicaid coverage to more people ages 16-64 with disabilities who work.

·             States will have the option to permit working individuals with incomes above 250 percent of the federal poverty level to buy in to Medicaid.

·             States may disregard some or all assets for these individuals.

·             The law creates a new Medicaid buy-in demonstration project to provide medical assistance to workers with impairments who are not yet too disabled to work.

·             The law also extends Medicare coverage for people with disabilities who return to work.  It extends Part A premium-free coverage for 4 ½ years beyond the current limit for Social Security disability beneficiaries who return to work.

 

Expedited Reinstatement of Benefits

·        Effective January 1, 2001, when a person’s Social Security or Supplemental Security Income disability benefits have ended because of earnings from work, he or she would be able to request reinstatement of benefits.

·        Beneficiaries must be unable to work because of their medical condition.  They must file the request for reinstatement with Social Security within 60 months from the month of their termination.

 

While Social Security is making a new determination, beneficiaries may receive up to six months of provisional benefits, including Medicare and Medicaid, as appropriate.

If Social Security decides that the medical condition no longer prevents the individual from working, the provisional benefits paid would not be considered an overpayment.

 

Continuing Disability Reviews

·        Effective January 1, 2001, Social Security cannot initiate a continuing disability medical review while a Social Security or SSI disability beneficiary is using a ticket.  Cash benefits may be subject to termination if earnings are substantial.

·        Effective January 1, 2002, work activity by a Social Security disability beneficiary who has received Social Security disability benefits for at least 24 months, could not be used as a basis for conducting a disability review.  However, the individual would be subject to regularly scheduled medical reviews.  Again, cash benefits may be subject to termination if earnings are substantial.

 

Work Incentives Advisory Panel

·        The law establishes a Work Incentives Advisory Panel within Social Security composed of 12 members appointed by the President and Congress. 

·        The Panel is to advise the Commissioner and report to Congress on implementation of the Ticket program. 

·        At least one-half of the Panel members are required to be individuals with disabilities, or representatives of individuals of disabilities, with consideration given to current or former Social Security disability beneficiaries.

 

Work Incentives Outreach Program

·        The law directs Social Security to establish a community-based work incentives planning and assistance program for the purpose of disseminating accurate information related to work incentives.

·        Social Security will establish a program of grants, cooperative agreements or contracts to provide benefits planning and assistance, including the availability of protection and advocacy services, and outreach.

·        The law also directs Social Security to establish a corps of work incentives specialists within Social Security.

 

Protection and Advocacy

The law authorizes Social Security to make payments to protection and advocacy systems established in each state to provide information, advice, advocacy and other services to disability beneficiaries.

 

Demonstration Projects and Studies

·        The law extends Social Security Disability Insurance demonstration authority for 5 years.  Under the law, Social Security is required to conduct a demonstration project to test reducing Social Security Disability Insurance benefits by $1 for each $2 that a beneficiary earns over a certain amount or amounts.

·        The implementation dates and locations for this demonstration will be announced.

 

Further information on the Ticket to Work and Work Incentives Improvement Act of 1999 is available on OESP’s web site at http://www.ssa.gov/work under “Legislation”.

 

Adapted from Matrix Advocacy Project—Philadelphia, PA

TITLE XVI: Supplemental Security Income (SSI)

TITLE II : Social Security Disability Insurance (SSDI) or Social Security Disabled Adult Child (SSDAC)

ligibility: to be eligible for TITLE XVI based on a mental or physical disability, an individual must: ·               Have little (under SGA) or no income; ·               Can get credit for subsidy or IWRE at initial application; (no SGA test after eligibility is established); ·               Have limited resources (under $2000); ·               Be considered medically disabled; ·               Be a citizen of the United States or a legal alien, and be a resident of the Country; and,     ·               File an application.   Cash Benefit:       The maximum amount for which one can be eligible is the sum of the Federal Benefit Rate    (FBR) plus any State supplement. This amount may be lower if the individual receives other Income.   Medical Coverage: Medicaid – no waiting period.   Checks Begin (Recipient): There is no waiting period required before receiving TITLE XVI benefits. Benefits are paid retroactive back to the month of application. No payment is made for the first month of eligibility.   Work Incentive Available while on TITLE XVI: Individuals on TITLE XVI can go to work and retain some, if not all of their benefits through the use of the Work Incentive provisions of the Social Security Act. These include: ·               Earned Income Exclusion; ·               Impairment-Related Work Expenses (IRWE); ·               Plan for Achieving Self-Support (PASS); ·               Student Earned Income Exclusion; ·               Blind Work Expense (BWE); ·               Property Essential to Self-Support; ·               1619(a) and Extended Medicaid [1619(b)]; ·               Section 301 Vocational Rehabilitation Client; and ·               Subsidy (only at initial application).   Checks Stop: An individual who has been receiving TITLE XVI will no longer receive checks when: ·               That person is determined to be no longer disabled; ·               “Countable Income” exceeds the “Break-Even  Point” (relates to cash benefit) (FBR x 2+GIE + EIE=BEP or when the countable unearned income plus the countable earned income exceeds the current FBR); ·               The threshold amount is earned   1999 Threshold: (relates to Medicaid for yr. 2000) Iowa                        $20,411.00 Kansas                    $21,735.00 Nebraska                 $22,403.00 Missouri                 $22,077.00 ; or ·               Resources exceed the individual limit of $2000.

Eligibility: to be eligible for TITLE II, a person must: ·               Have worked and paid Social Security taxes (FICA), be a qualified worker (20/40 quarters), or an adult disabled child (SSDAC) of a qualified worker; ·               Have little (under SGA) or no current earned income; ·               Be considered medically disabled; ·               Be a citizen of the United States, or a legal alien, and be a resident of this Country; and, ·               File an application. SSDAC Eligibility: ·               Disability began before age 22; ·               Must be 18 years old and unmarried; ·               The qualified worker (parents, sometimes grandparents) must meet one of the following criteria: 1. Deceased 2. Retired 3. Experience a disability & eligible for SSDI   Cash Benefit (Entitlement): The payment amount is based on the individual’s lifetime average earnings covered by Social Security. Workman’s compensation payments and/or public disability payments may reduce the payment amount.   Medical Coverage: Medicare after two years.   Checks Begin: An individual must wait five (5) full months after the onset of the disability before receiving TITLE II benefits. There may be up to 12 months of retroactivity, if applicable.   Work Incentives Available While on TITLE II:               Individuals on TITLE II can return to work and               retain their benefits through the proper use of the               Work Incentive provisions of the Social Security               Act. These include: ·               Higher SGA for Beneficiaries who are Blind; ·               A Trial Work Period; ·               Extended Period of Eligibility; ·               Impairment Related Work Expenses (IRWE); ·               Subsidy; ·               Continuation of Medicare Coverage; ·               Medicare for People with Disabilities who Work; ·               Section 301 Vocational Rehabilitation Client; and ·               PASS, TITLE II beneficiaries can use their cash benefit to pay for PASS expenditures only if employment will result in termination of TITLE II cash benefits.   Checks Stop: An individual who has been receiving         TITLE II will no longer receive checks: ·               When a person is determined to no longer  be disabled; ·               The first month after the end of the Extended Period of Eligibility when income is over SGA.