TN 46 (10-14)

DI 11005.056 Signature Requirements for Form SSA-827

Citations:

P.L. 104-191 Health Insurance Portability and Accountability Act of 1996 (HIPAA);

20 U.S.C. §1232g Family Education Rights and Privacy Act (FERPA);

38 U.S.C. §7332;

42 U.S.C. §290dd-2;

34 CFR Parts 99 and 300;

38 CFR 1.475;

42 CFR Part 2;

45 CFR Parts 2, 160, and 164; and State law.

A. Obtaining one signed Form SSA-827

Generally, the field office (FO) obtains one signed Form SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)) from the claimant (or proper applicant) at each adjudicative level (initial, reconsideration, and hearing) to process disability claims, continuing disability reviews, or non-disability claims in which capability is an issue.

Do not make annotations, including check marks, to indicate where to complete and sign the form. Use a cover note (“sticky” note) if guidance is necessary.

For information on FO responsibilities when the claimant fails to provide a signed Form SSA-827, see DI 11018.005.

1. What we mean by “one” Form SSA-827

Federal law permits sources with information about the claimant to release that information if the person authorizing disclosure signs one authorization to release all of the claimant’s information from all of the claimant’s possible sources (unless there are other state requirements).

Generally, the adjudicating component (for example, the disability determination services (DDS) or the hearing office) makes copies of the signed form to send to each source. If needed later, the adjudicating component obtains an additional original signed and dated Form SSA-827. However, any local adjudicating component can make special arrangements with an FO to obtain more than one signed Form SSA-827.

NOTE: A properly completed and legible pen and ink signed Form SSA-827 is acceptable if submitted in person, by mail, or by fax or scan. We also accept forms signed by other means, such as via SSA’s Internet click-and-sign process and by our attestation process.

2. Signing and dating Form SSA-827

Form SSA-827 must include the appropriate signature and date of signing.

Acceptable signature methods for Form SSA-827 are:

  • pen and ink signature on a paper Form SSA-827;

  • SSA’s Internet click-and-sign process; or

  • SSA’s attestation process.

IMPORTANT: We require pen and ink signatures in any situation where we do not permit the Internet or attestation signature processes. For an explanation of when we permit the Internet or attestation signatures, see DI 11005.056D., in this section.

3. If claimant inadvertently submits an undated Form SSA-827

Never instruct the claimant to provide an undated Form SSA-827. If the claimant submits an undated Form SSA-827, return it to the claimant for dating.

B. Authority to authorize disclosure of the claimant’s medical and education records

In most cases, the claimant authorizes disclosure of his or her records by signing Form SSA-827. However, an authorized individual other than the claimant may sign Form SSA-827 authorizing disclosure in the situations detailed in DI 11005.056C in this section.

Generally, mark the appropriate sign box to sign as:

1. Parent of minor

The parent must have authority to make health care decisions and educational decisions for the minor child claimant.

2. Guardian of minor

The individual must be the legal guardian of the claimant. For more information on guardianship, see GN 00502.139B.

3. Other personal representative

Generally, the personal representative is someone other than a guardian who has authority to make health care decisions for the claimant under state law. The personal representative must explain the basis of his or her authority to sign the Form SSA-827 in the space provided on the form.

IMPORTANT: Designation as either a representative payee or appointed representative is not a legal basis to sign the Form SSA-827 authorizing disclosure as an “other personal representative.” Information on personal representatives is available at the U.S. Department of Health & Human Services website: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/personalreps.html.

C. Form SSA-827 signature requirements for special situations

1. Physically unable to sign

Whenever a claimant agrees to authorize disclosure, but is physically incapable of signing by permissible means (for example, pen and ink, click and sign, and attestation), see the following actions:

a. The FO actions

  • annotates “Individual physically unable to sign” in the “INDIVIDUAL authorizing disclosure” box; and

  • alerts the DDS of the situation by annotating the “Remarks” screen on the Electronic Disability Collect System (EDCS) 3367.

b. The DDS actions

  • explains in a cover letter to the medical source that the claimant is physically unable to sign Form SSA-827; and

  • provides the medical source a copy of Form SSA-827 with the annotation “Individual physically unable to sign” in the “INDIVIDUAL authorizing disclosure” box.

2. Incompetent or comatose adult

a. Court-appointed representative available

If a court has deemed the claimant incompetent, the claimant should not sign the SSA-827. The guardian, or other person authorized under state law to act on the claimant’s behalf, must:

  • sign in the “INDIVIDUAL authorizing disclosure” box;

  • mark the appropriate entry in the “IF not signed by subject of disclosure” relationship block, such as parent or guardian; and

  • if he or she signs as “other personal representative,” then explain the basis for personal representative authority in the space provided.

b. Court-appointed representative not available

When the claimant is unable to sign Form SSA-827. but does not have a legally appointed representative, the proper applicant who signed the application on behalf of the claimant should:

  • sign in the “INDIVIDUAL authorizing disclosure” box;

  • mark the appropriate entry in the “IF not signed by subject of disclosure” relationship block, such as parent or guardian; and

  • if he or she signs as “other personal representative,” then explain the basis for authority to sign in the space provided.

For an explanation of proper applicant policy, see GN 00204.003.

3. Minor child claimant age 12 or older

If the claimant is age 12 or older, but still considered a minor under state law, both the claimant and his or her parent, guardian, or other person authorized by state law to act for the claimant must sign Form SSA-827. We do not permit attestation in this situation.

Obtain both signatures and date of signing as follows:

  1. The claimant (child) signs in the “INDIVIDUAL authorizing disclosure” signature box on the left; and

  2. The parent, guardian, or other authorized personal representative:

    • marks the appropriate entry in the “IF not signed by subject of disclosure” relationship block;

    • signs in the box below the check boxes; and

    • if he or she signs as “other personal representative,” then he or she explains the basis for authority to sign in the space provided.

  3. Ensure the “Date Signed” box is completed with the date of signing.

EXCEPTION 1: If the claimant's parent or guardian has a strong objection to the claimant signing Form SSA-827, and the source will accept Form SSA-827 without the signature of the child, the FO may waive the requirement for the child’s signature. In that case, document the waiver in the “Remarks” screen on the EDCS 3367, and follow the same instructions for minor child under age 12 in DI 11005.056C.4 in this section. If the source requires both signatures, explain this to the parent or guardian and follow the instructions in DI 11005.056D.2.b in this section.

EXCEPTION 2: If state law provides for confidential treatment of minor persons (that is, when state law does not require the consent or knowledge of parents or guardians), we only need the claimant to sign the authorization.

4. Minor child under age 12

When the claimant is under age 12, the child’s applicant should:

  • sign in the “INDIVIDUAL authorizing disclosure” box;

  • mark the appropriate entry in the “IF not signed by subject of disclosure” relationship block; and

  • if he or she signs as “other personal representative,” then he or she explains the basis for authority to sign in the space provided.

NOTE: We permit attestation in this situation because we obtain only one signature.

D. Alternative signature processes for Form SSA-827

1. Internet click-and-sign process

Adult claimants (age 18 or older) who complete an iClaim/i3368 (Internet Benefit Application/Internet Adult Disability Report) or i3441 (Internet Disability Report - Appeal) on their own behalf may choose to use the Internet to sign and submit Form SSA-827, along with the i3368 or i3441. If the claimant agrees to sign Form SSA-827, clicking on the “Submit” button at the end of the i3368 or i3441 represents the claimant’s intent to sign and submit the forms to SSA.

When the claimant signs Form SSA-827 with the internet click and sign process, we consider it signed when the claimant submits it. SSA systems then propagate the claimant’s name (that is, “Electronically Signed By (first, middle, last name, and suffix)”), the date, and the claimant’s identity information (based on information already entered during completion of the i3368 or i3441) onto an electronic version of Form SSA-827. The claimant can print a copy of the signed Form SSA-827 for his or her records.

At any time before submitting the signed Form SSA-827, the claimant can opt out of the Internet process and continue with the pen and ink signature process, even if he or she completes the i3368 or i3441. The claimant can also choose not to submit a Form SSA-827.

2. In-office and telephone attestation process

a. When attestation is permitted

The SSA or DDS employee may use the attestation process in DI 11005.056D.2.d, in this section, to obtain a signed and dated Form SSA-827 when the following conditions exist:

  1. The claimant is one of the following:

    • an adult (age 18 or older) who is signing on his or her own behalf, or

    • a child (under age 18) who is signing on his or her own behalf, or

    • a child whose claim is being pursued by an individual with the authority to sign on behalf of a child claimant (for example, a parent or guardian).

  2. The case is available in eView; and

  3. The individual signing the Form SSA-827 chooses to sign using the attestation process in one of the following situations:

    • during a FO disability interview (for example, in office, video conference, or teleclaim interview), or

    • via face-to-face or telephone contact with an SSA or DDS employee.

b. When attestation is not permitted

We do not permit attestation when:

  1. The claimant has not reviewed Form SSA-827.

    Claimants must have the opportunity to review Form SSA-827 before we permit attestation.

  2. Two signatures are required.

    When the claimant and another person (for example, a parent, guardian, or other personal representative) need to sign Form SSA-827, use a paper form with a pen and ink signature.

  3. The individual chooses not to attest.

    At any time before completing the attestation process, the individual can opt out of the attestation process and continue with the paper (pen and ink signature) process.

    NOTE: If the claimant chooses not to submit Form SSA-827, see DI 11018.005 for FO responsibilities when a claimant fails to cooperate.

  4. The claim is an Electronic Disability Collect System (EDCS) exclusion without an associated electronic folder.

c. How attestation works

  1. The SSA or designated State agency employee (the employee) confirms the individual’s (claimant or form signer) intent to sign Form SSA-827 and to authorize disclosure of information to SSA. If the individual agrees, the employee attests to the individual’s intent to authorize disclosure by clicking the “Attest, Submit, and Print” buttons in EDCS or eView. The employee's act of attesting to these facts documents the individual’s agreement. The process of the individual agreeing and the employee attesting constitutes a signature.

  2. SSA systems then propagate the individual’s name (that is, “Electronically Signed By (first, middle, last name, and suffix)”), the date, and the individual’s identity information (based on information already collected) on an electronic version of Form SSA-827. In addition, SSA systems propagate the employee’s information (that is, “Attested by SSA or Designated State Agency Employee first initial, last name”) and office phone number, city, state, and ZIP code in the witness block on the electronic version of the form.

  3. The employee provides a printed, paper copy of the signed Form SSA-827 to the individual for his or her records.

d. In situations where we permit attestation, follow these procedures:

  1. Provide the individual the opportunity to review Form SSA-827.

    For telephone interviews or contacts, you may either:

    • direct the individual to a copy of the form online: http://www.ssa.gov/online/ssa-827.pdf, or

    • provide a copy in advance with the appointment letter, or Disability Starter Kit.

      Do not continue with the attestation process if the individual has not had the opportunity to review Form SSA-827.

      Proceed with the attestation process once the individual has reviewed the form, or obtain a pen and ink signed and dated paper Form SSA-827.

  2. For child claims:

    • select or enter the name of the individual authorized to sign Form SSA-827.

    • if you enter an individual’s name, you must enter his or her address and telephone number.

    • select the basis for that individual’s authority to sign the form (that is, parent of minor, guardian, or other personal representative).

    • if an “other personal representative” is signing, you must document his or her explanation for authority to sign in the space provided. For more information about personal representatives, see DI 11005.056B.3., in this section.

  3. Read the scripted language on the SSA-827 eAuthorization screen in EDCS, eView, or as written in DI 11005.056D2.e., in this section.

  4. Indicate the individual’s intent to authorize disclosure by selecting “Yes” or “No.”

    • If “Yes,” attest to the individual’s intent to authorize disclosure by clicking the “Attest, Submit, and Print” buttons.

      NOTE: The system automatically adds the signed Form SSA-827 to the electronic folder. You do not need to fax or scan the form into the electronic folder.

    • If “No,” select the reason for declining and provide the individual the opportunity to complete a paper Form SSA-827 with a pen and ink signature.

  5. Provide the printed copy of the signed Form SSA-827 to the individual for his or her records.

    REMEMBER: We do not permit attestation in any situation where two signatures are required.

e. Scripts for attestation

  1. In-office interview or contact

    “Here is a printed copy of the SSA-827 for your review. We will ask you to acknowledge that you have read the SSA-827 (Authorization to Disclose Information to the Social Security Administration), and confirm your intent to sign this form. It will be used to request all of (your or claimant’s name) medical records and other information related to (your or claimant’s name) ability to perform tasks.

    • Do you understand that the SSA-827 that you have read will be used to request all of (your or claimant’s name) medical records and other information related to (your or claimant’s name) ability to perform tasks?

    • Do you agree to authorize disclosure of (your or claimant’s name) information to Social Security?”

  2. Telephone interview or contact

    “We will ask you to acknowledge that you have read the SSA-827 (Authorization to Disclose Information to the Social Security Administration), and confirm your intent to sign this form. It will be used to request all of (your or claimant’s name) medical records and other information related to (your or claimant’s name) ability to perform tasks.

    • Do you understand that the SSA-827 that you have read will be used to request all of (your or claimant’s name) medical records and other information related to (your or claimant’s name) ability to perform tasks?

    • Do you agree to authorize disclosure of (your or claimant’s name) information to Social Security?”


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