Form Approved

OMB No. 0960-0566

Social Security Administration

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
SenioRx 2620 Centenary Blvd.

Bld. 2 Suite 100

Shreveport, LA 71104

I want this information released because:

Free Medication

(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)

_ü_ Monthly Social Security benefit amount

_ü_ 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 a 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 Internet (12/99)

Attention:

Dora Miller