Ssa 1696 pdf

SSA has a system called Electronic Records Express that allows representatives to upload electronic medical records. Since ERE is state-specific , we recommend contacting one of the following resources to learn more:. When you drop off the application packet, note whom you delivered it to and confirm that they have everything they need.

It is very important to get in touch with the DDS examiner assigned to the application and establish open lines of communication. Contact the DDS examiner, introduce yourself, and see if they have all of the information they need. DDS will make a medical decision on the application once they have all of the necessary information. Section 3 — Principal Representative Claimant Only If you are the only representative for the claimant, this section can be left blank.

If the claimant wants to have more than one representative, they will add the name of the principal representative here. Only the person named the principal representative will receive copies of the communications to the claimant. The mailing address will be your agency address, as this is where SSA and DDS will send mail related to the application. It is important to answer all status-related questions.

Affiliation Information: The questions related to Affiliation are about your organization and only for those who are seeking a fee.

Since you will not be seeking a fee for SOAR assistance, this will be left blank. It is. Social Security matters. We give more information, and. Sections a and d of the Social Security Act,. Furnishing us this information is voluntary. However, if. Administration SSA , then you and that individual must.

We rarely use the information you supply for any purpose. However, we may use the information for. To facilitate statistical research, audit, or. A complete list of when we may share your information. Act System of Records Notice entitled, Appointed. Representative File, Additional information. We may share the information you provide to other. Matching programs compare our records with records.

We use the information from these programs to. Please print or type your answers on this form. At the top. Security number. If your claim is based on another. If you. Part I Claimant's Appointment of Representative. Give the name and address of the individual s you are. You may appoint an attorney or any other. You also may appoint.

You can appoint one or more. Check the block s showing the program s under which. You may check more than one block. Form SSAU4 ef When you give your permission your representative may. If you want to give your. If you will have more than one representative, check the. SSA will make. You must sign and date the form. Print or type your. If you are appointing a representative to replace a.

Each individual you appoint in Part I should also complete. If your representative is seeking. Identification Number EIN.

We will provide both your representative and the employer, entity, or firm with a copy of the form IRS. For more information on form MISC and employer registration, visit our website at. Your representative should also certify the accuracy of all statements in this section.

Section 5 - Representative's Status, Affiliations, and Certifications. Sections and d of the Social Security Act, as amended, allow us to collect this information. Furnishing us this. However, failing to provide all or part of the information may prevent us from appointing a representative.

We will use the information to verify the appointment of your representative and his or her acceptance of the appointment. In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where. Additional information and a full listing of all our. SORNs are available on our website at www. Either you or your representative can complete this section. Check all types of claims for which you seek representation.

Complete this section, if your representative is or will be asking for a fee for services performed on your claim. Generally, to. Your representative may waive the right to charge you a fee. In these situations, the third party. If your representative is eligible for direct payment, he or she also may waive. You must sign and date this section. If your representative is not an attorney, he or she also must sign and date this section.

This information collection meets the clearance requirements of 44 U. Reduction Act of You do not need to answer these questions unless we display a valid Office of Management and Budget.