SI 00520.930 Exhibits of Prerelease Agreements, Referrals, and Forms

EXHIBIT 1 - Model Prerelease Agreement between SSA and non-BOP Institution

EXHIBIT 2 - Model Prerelease Referral

EXHIBIT 3 – Modified Form SSA-3288 (Consent for Release of Information) for use in BOP prerelease claims

EXHIBIT 1 - Model Prerelease Agreement between SSA and non-BOP institution

NOTE: This agreement is just a model; it can be modified to meet the needs of the local institution. All new agreements should be sent to the RO for review and any, substantial deviations from the model should then be sent to Office of the General Counsel (OGC) for review prior to enacting a new agreement. For more information about establishing prerelease agreements with non-BOP institutions, including time frames for processing claims using prerelease procedures, see SI 00520.910C.

FOs and ROs must establish operating procedures to store and maintain prerelease agreements.

EXHIBIT 2 - Model Prerelease Referral from Facility to SSA Office


Agency: ___________________________	Social Worker: _______________
Building/Unit: ______________________	Phone: ______________________

Name of Resident: _________________________	Anticipated Date of Release: _____________________

Social Security Number: _____________

Date of Birth: ______________________

Reason for Referral:_________________

EXHIBIT 3 - Modified Form SSA-3288 (Consent for Release of Information) for use in BOP prerelease claims

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To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0500520930

SI 00520.930 - Exhibits of Prerelease Agreements, Referrals, and Forms - 01/08/2025
Batch run: 01/08/2025
Rev:01/08/2025

Program Operations Manual System (POMS)

SI 00520.930 Exhibits of Prerelease Agreements, Referrals, and Forms