Availability

Link: http://www.ssa.gov/online/ssa-3288.pdf

 

Instructions

Updated: 4/2002

Note: Instructions for Medicaid Eligibility and Texas Works are listed separately below.

MEDICAID ELIGIBILITY INSTRUCTIONS

INTRODUCTION

On August 22, 1996, Public Law 104-193, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, was enacted. Under this new law only certain excepted classes of qualified aliens are eligible for supplemental security income (SSI) and food stamps. This exception involves aliens who are lawfully admitted to the United States for permanent residence under the Immigration and Nationality Act and who have worked or can be credited with 40 qualifying quarters (QQ). Under certain conditions, the QQs of parents or spouses can be added to the alien's record to achieve the needed 40 QQs. The Social Security Administration (SSA) is the primary source for information on QQs and provides this information via the Wire Third Party Query (WTPY) automated system, only after a Consent for Release of Information (SSA-3288) is completed and signed.

PURPOSE

After determining which Social Security numbers are needed to request QQs histories on, the Consent for Release of Information forms (SSA-3288) must be obtained. Federal regulations mandate that a Consent for Release of Information (SSA-3288) must be completed and signed, before requesting the 40 qualifying quarters of coverage information for the applicant/recipient, the parent(s) and/or spouse.

A Consent for Release of Information (SSA-3288) must be signed by each individual whose work history will be used to establish the 40 quarters of coverage information. However, a consent form is not needed when requesting information on a deceased individual's Social Security Number.

Important: If someone refuses to cooperate and will not complete the consent form, do not request the 40 QQs information. SSA cannot and will not provide the information. A signed SSA-3288 must be obtained and is necessary because these records are protected by the Privacy Act.

PROCEDURE

Form Retention

Do not send the completed SSA-3288 to SSA. The forms must be retained in the case folder. SSA will request to see these forms as part of their annual security audit of the Texas Department of Human Services or if a question is raised.

How to Complete the SSA-3288

This consent form (SSA-3288) must be completed and signed only by:

  • the person to whom the information or record applies, or
  • the parent or legal guardian of a minor to whom the nonmedical information applies, or
  • the legal guardian of a legally incompetent adult to whom the information applies.

Note: Do not use the SSA-3288 to request information about earnings or employment history.

DETAILED INSTRUCTIONS

Complete the shaded items only:

  • fill in the name, date of birth, and Social Security Number of the person to whom the information applies;
  • fill in the name and address of the Texas Department of Human Services, and the name of the client/applicant;
  • fill in the reason for requesting the information;
  • check the following type(s) of information:
    • Social Security Number;
    • identifying information (includes date and place of birth, parents' names);
    • other (specify): Quarters of Coverage History (a qualifying quarter cannot be credited before 1937);
  • have the individual sign and date the form; and
  • fill in Relationship (to the client/applicant).

 

TEXAS WORKS INSTRUCTIONS

PURPOSE

To obtain an individual's consent for DHS to submit a request to SSA for verification of 40 quarters of earnings.

PROCEDURE

When to Prepare

Worker must complete the form for each person for whom verification of 40 quarters if being requested.

Form Retention

Retain the original signed form in the casefolder until no longer needed.

DETAILED INSTRUCTIONS

Enter the name, date of birth, and Social Security number of the person for whom 40 quarter information is requested. Exception: No signature is required if the spouse or parent is deceased.

Workers must ensure that a signature is obtained for each person for whom a consent form is completed.

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