Fill and Sign the Modified Benefit Formula Questionnaire Foreign Pension

IFneeded, second witness sign here (e.g., if signed with "X" above) The Social Security Administration and to the State agency authorized to process my case (usually called "disability determination services"), including contract copy services, and doctors or other professionals consulted during the process. [Also, for international claims, to the U.S. Department of State Foreign Service Post.] IF not signed by subject of disclosure, specify basis for authority to sign (Parent/guardian/personal representative sign here if two signatures required by State law) Parent of minor Other personal representative (explain) Guardian WITNESS I know the person signing this form or am satisfied of this person's identity: - - Phone Number (or Address) ** PLEASE READ THE ENTIRE FORM, BOTH P AGES, BEFORE SIGNING BELOW ** AUTHORIZATION TO DISCLOSE INFORMATION TO THE SOCIAL SECURITY A DMINISTR A TION (SSA ) Phone Numbe r(with a rea code ) Date Signed City State ZIP - Form Approved OMB No. 0960-0623 I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange) : OF WHAT All my medical records; also education records and other in formation related to my ability to perform tasks. This includes specific permission to release: 1. All records and other information regarding my treatment, hospitalizat ion, and outpatient care for my impairment(s) including , and not limited to : -- 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 -- Records which may indicate the presence of a communicable or venereal disease which may include, but are not limited to, diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS); and tests for HIV. -- Gene-related impairments (including genetic test results) 2. Information about how my impairment(s) affects my ability to complet e tasks and activities of daily living, and affects my ability to work. 3. Copies of educational tests or evaluations, including Individualized Educational Programs, triennial assessments, psychological and speech evaluations, and any other records that can help evaluate function; also teachers' observations and evaluations. 4. In formation created within 12 months a fter the date this authorization is signed, as well as past in formation. TO WHOM PURPOSE EXPIRES WHEN This authorization is good for 12 months from the date signed (below my signature).