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Authorizes SSA to obtain medical records, school records, and other information from sources such as doctors, hospitals, and employers when processing your disability or benefits claim.
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Authorizes SSA to obtain medical records, school records, and other information from sources such as doctors, hospitals, and employers when processing your disability or benefits claim.
Plain English
This form gives SSA permission to collect information about you from your doctors, hospitals, schools, and other organizations to evaluate your disability claim.
Submission Date
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Claimant Info
4 items
Your full legal name.
Your SSN to identify your claim.
Your date of birth.
Any other names under which records may be filed.
Authorization
2 items
Sign to authorize SSA to obtain your records.
Date you signed the authorization.
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This form gives SSA permission to collect information about you from your doctors, hospitals, schools, and other organizations to evaluate your disability claim.
Disability applicants and claimants who need SSA to gather supporting documentation on their behalf.
A consent form authorizing SSA to obtain medical, school, employment, and other records relevant to your claim.
Required when you apply for disability benefits (SSDI or SSI) and whenever SSA needs to gather new evidence.
Submit along with your disability application at your local SSA office or online.
Sign and date the form. SSA will use it to contact your healthcare providers and other sources directly.
SSA needs this authorization to legally request your private medical and other records from third parties.
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