This is an archival or historical document. It may not reflect current policies or procedures.

Why we need this form

Your written authorization allows us to get what we need from your doctors, hospitals, schools and other sources that have records about you. Those records will help us make a decision about your eligibility for disability benefits.

Who must sign

Individuals applying for disability must sign and date the Medical Release form for themselves, even if someone else is helping them with the application process. We can make an exception only when the disabled person has a legal guardian or is deceased.

A competent adult (spouse, friend, social worker, etc.) must witness the signature. Many sources will not honor this request for information unless it is witnessed. A second witness is not usually required unless the individual authorizing disclosure signs with an "X."

What to do

  1. Print and read both pages. The information on page 2 of the form explains more about how we use this form and the possible consequences of not signing.

  2. In the upper right corner, write the name, Social Security Number, and date of birth of the person applying for disability benefits. Do not write in the large empty box in the middle of the form.

  3. Sign the form:

  4. Date the form.

  5. Write the address and daytime phone number of the individual signing the form.

  6. Have the witness sign and write his or her phone number or address in the WITNESS section.