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How SSA-827 Meets Requirements for Authorization
to Disclose Information
(1)
Core
elements required:
(i)
Description
of information to be disclosed
(ii)
Person
or class authorized to disclose
(iii)
The person
or class to whom disclosed
(iv)
Purpose
of disclosure
(v)
Expiration
date
(vi)
Signature
and date
(2)
Required
statements (i) The individual's right to revoke the authorization in writing, and either: (A) The exceptions to the right to revoke and a description of how the individual may revoke the authorization. (ii) The ability or inability to condition treatment, payment, enrollment or eligibility for benefits on the authorization, by stating either:
(iii)
The potential for information
disclosed pursuant to the authorization to be subject to re-disclosure
by the recipient and no longer be protected by this subpart.
Note:
SSA is also aware of the
strict limits on re-disclosure of information covered by 42 CFR Part 2
and specifically addresses this on the SSA-827.
Other Considerations
Details of how SSA-827 meets requirements --Psychological, psychiatric or other mental impairment(s) (excludes "psychotherapy notes" as defined in 45 CFR 164.501 --Drug abuse, alcoholism, or other substance abuse --Sickle cell anemia --Human immunodeficiency virus (HIV) infection (including acquired immunodeficiency syndrome (AIDS) or tests for HIV) or sexually transmitted diseases --Gene-related impairments (including genetic test results) Information created within 12 months after the date this authorization is signed, as well as past information. Note: "For example, if the Social Security Administration seeks authorization for release of all health information to facilitate the processing of benefit applications, then the description on the authorization form must specify "all health information" or the equivalent." (65 Federal Register 82517, December 28, 2000) "Disclosures to SSA . made pursuant to an individual's completed SSA-827 authorization form, or any other valid authorization, are exempt from the minimum necessary requirements of the Privacy Rule." (April 25, 2003 DHHS letter).
Note: "One
authorization form may be used to authorize disclosures by categories
of covered entities, without naming particular covered entities."
TO
WHOM Note: "[A]n authorization could be completed by an individual and given to a government agency, authorizing the agency to receive medical information from any health care provider that has treated the individual within a defined period of time. Such an authorization is permissible . if it sufficiently identifies the government entity that is authorized to receive the disclosed protected health information." (65 FR 82518, December 28, 2000). Determining my eligibility for benefits, including looking at the combined effect of any impairments that by themselves would not meet SSA's definition of disability; and whether I can manage such benefits. Note: "[O]ne authorization form may
be used when disclosure of the same protected health information is being
sought for multiple purposes, as long as an authorization for the disclosure
of psychotherapy notes is not combined with an authorization for the disclosure
of any other protected health information." Note: "A covered entity may disclose
the protected health information specified in the authorization, even
if that information was created after the authorization is signed, as
long as the authorization has not expired or been revoked in writing."
(April 25, 2003
DHHS letter). INDIVIDUAL authorizing disclosure
Witness: In this section of the English SSA-827, one who knows the person signing the form should sign as a witness and provide his or her phone number or address. There is space for a second witness if needed. Note: "All authorizations must be in writing and signed. We intend e-mail and electronic documents to qualify as formal written documents." (65 FR 82660, December 28, 2000) "We do not require verification of the individual's identity or authentication of the individual's signature." (65 FR 82518, December 28, 2000) "A copy, facsimile, or electronically transmitted version of a signed authorization is also a valid authorization under the Privacy Rule." (April 25, 2003 DHHS letter).
Signing
this form is voluntary, but failing to sign it, or revoking it before
we receive necessary information, could prevent an accurate or timely
decision on your claim, and could result in denial or loss of benefits.
Although the information we obtain with this form is almost never used
for any purpose other than those stated above, the information may be
disclosed by SSA without your consent if authorized by Federal laws such
as the Privacy Act and the Social Security Act. 1. To enable a third party (e.g., consulting physicians) or other government agency to assist SSA to establish rights to Social Security benefits and/or coverage; 2. Pursuant to law authorizing the release of information from Social Security records (e.g., to the Inspector General, to Federal or State benefit agencies or auditors, or to the Department of Veterans Affairs (VA); 3. For statistical research and audit activities necessary to ensure the integrity and improvement of the Social Security programs (e.g., to the Bureau of the Census and private concerns under contract with SSA). All personal information SSA collects is protected by the Privacy Act of 1974. Once medical information is disclosed to SSA, it is no longer protected by the health information privacy provisions of 45 CFR part 164 (mandated by the Health Insurance Portability and Accountability Act (HIPAA). SSA retains personal information in strict adherence to the retention schedules established and maintained in conjunction with the National Archives and Records Administration. At the end of a record's useful life cycle, it is destroyed in accordance with the privacy provisions, as specified in 36 CFR part 1228. Social Security Administration |
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Last reviewed or modified Thursday May 17, 2012 |