Consent for Release of Information

TO: Social Security Administration

______________________________ _____________________ ______________________

Name Date of Birth Social Security Number

I authorize the Social Security Administration to release information or records about me via facsimile or postal correspondence, to:

I want this information released because:

I need proof of disability for the determination of eligibility for the Iowa Department for the Blind. Please send Verification of Benefits

Please release the following information:

_____ Social Security Number

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

__X__ Monthly Social Security benefit amount

__X__ 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)__________________________________________

__x__ Other (specify): See below.

Cash: Type of Benefit(s), current payment status, statutory blindness, date of disability onset, date of entitlement, Gross & net amount of benefits, others paid on the record, total family cash benefit, overpayment balance, monthly amount withheld.

Medical Reviews: Next medical review, medical re-exam cycle

Representation: Representative payee, authorized representative

Health Insurance: Type of Medicare (part A, part B, part C/D), start date, stop date, buy-in or subsidy, Medicaid eligibility, start date, stop date, buy-in or subsidy.

Title XVI (SSI) Work Exclusion: Blind work expenses, impairment-related work expenses, student earned income exclusions, pass exclusion, SSI earnings.

Title II (SSDI) Work Exclusion: Trial work months, start date, end date, number of months used, month of cessation, current SGA level.

I am the individual to whom the information/record applies or that person’s parent (if a minor) or legal guardian. I declare under penalty of perjury that I have examined all the information on this form and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

Signature:__________________________________________________________________

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

Date: ________________________ Relationship: ______________________________