Page 61

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 March 2011 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 3 5

Social Security Administration OMB No. 0960-0567

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 to:

NAME ADDRESS

I want this information released because:

(There may be a charge for releasing information.)

Please release the following information:

Social Security Number

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

Monthly Social Security benefit amount

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)

Other (specify)

I am the individual to whom the information/record applies or that person’s parent (if minor) or legal guardian. I know that if I make any representation which I know is false to obtain information from Social Security records, I could be punished by a fine or imprisonment or both. Signature:

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

Date:

Relationship:

SSA-3288