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Social Security Administration
Claimant's Appointment of a Representative
Page 3 of 6
OMB No. 0960-0527
Section 1 - Reason for Submission and Claimant's Information Reason for Submission
Check the box indicating your reason for submitting this form. If you or your representative are submitting this form to update information provided in your submission, please check the "Update" box and check the box(es) specifying the information you or your representative are updating.
Appoint a new representative
Update information you previously submitted (Specify below by checking all applicable boxes) Claimant's Principal Representative (Section 3)
Claim Type (Section 4)
Representative's Status, Disqualifications or Suspensions (Section 5, Part A) Representative's Affiliation Information (Section 5, Part B) Assignment of Direct Payment of Authorized Fee to an Entity (Section 5, Part C) Fee Arrangement (Section 6)
Other Claimants (Section 7)
Claimant's Information
First Name Initial Last Name
Claimant's Social Security Number
- -
Number Holder's Information (Complete only when applicable) My claim is based on another person’s work or earnings (e.g., spouse, parent). This person’s information is different from mine. Number Holder's Social Security Number
- -
First Name Initial Last Name
Section 2 - Representative's Information
All representatives must register and receive a Representative Identification (Rep ID). For more information about registration visit us on-line at www.ssa.gov/ar, contact us at 1-800-***-**** (TTY 1-800-***-****) or visit your local Social Security office. If your representative wishes to update their registration information, they must do so using Form SSA-1699 Representative Registration.
First Name Initial Last Name
Registered Representative Rep ID
Docusign Envelope ID: B50701B3-8580-4FCC-B865-550672CA04FF Jose Sanchez
Form SSA-1696 (12-2024) UF Page 4 of 6
Claimant's Social Security Number
- -
Representative's Rep ID
Section 3 - Claimant's Principal Representative (Complete only when applicable) I have appointed more than one representative. The person named below is my principal representative. I ask SSA to make contacts or send notices to this person. Any principal representative I named before is no longer my principal representative but is still one of my representatives unless I have filed a separate writing revoking their appointment. Name:
Section 4 - Claim Type
I appoint the individual named in Section 2 to act as my representative in connection with my claim(s) or asserted right(s) under Title II (RSDI), Title XVI (SSI), Title XVIII (Medicare Coverage), and Title VIII (SVB) of the Social Security Act, as presently amended, specifically for the issues identified below: (Check all that apply) Claim/Appeal for Title II Disability Benefits
Claim/Appeal for Title XVI Disability Benefits
Claim/Appeal for Title XVI Benefits
Claim/Appeal for Retirement Benefits
Claim/Appeal for Title XVIII (Medicare), VIII (Special Veteran's Benefits) Continuing Disability Review (CDR)
Post-Entitlement Issue (A new issue you raise after eligibility for other benefits)
(E.g., benefit amount, representative payee, suspension, termination, overpayment.) Section 5 - Representative's Status, Affiliations, and Certifications Part A - Representative's Status, Disqualifications or Suspensions
(Representatives must always keep this information current) I am an attorney (SSA rules state that a claimant may appoint an attorney in good standing who has the right to practice law before a court of a State, Territory, District, or island possession of the United States, or before the Supreme Court or a lower Federal court of the United States.)
I am a non-attorney eligible for direct payment (SSA rules require that non-attorneys meet certain criteria to qualify for direct payment. See our website at www.ssa.gov/representation for the criteria). I am a non-attorney not eligible for direct payment. I am now or have previously been (check all that apply): Disbarred or suspended from a court or bar to which I was previously admitted to practice law. If selected, explain:
Disqualified from participating in or appearing before a Federal program or agency. If selected, explain:
Removed from practice or has/had any or all licenses suspended by a professional licensing authority or agency. If selected, explain:
Docusign Envelope ID: B50701B3-8580-4FCC-B865-550672CA04FF Form SSA-1696 (12-2024) UF Page 5 of 6
Claimant's Social Security Number
- -
Representative's Rep ID
Part B - Representative's Affiliation Information
If you want to designate an affiliate (business, firm, or other organization) for this claim, provide the entity's name and Employer Identification Number (EIN) here. This number is not your Social Security number (SSN). This number is the entity's tax identification number. To designate an affiliate entity for this claim, you must have already submitted to us a Form SSA-1699 that identifies this entity as an affiliate. (If you do not want to designate an affiliate entity for this claim, or do not qualify for or seek direct payment, mark no EIN.)
EIN - No EIN
Entity’s Name (Enter the full name of the business, firm, or organization with which you want to be affiliated while representing this claim)
Part C - Assignment of Direct Payment of Authorized Fee to an Entity
(Complete only when applicable)
Check the Assignment box below if you want to assign direct payment of your fee to the entity you identified above in Part B. If you previously assigned direct payment to another entity, an assignment to a new entity in Part B also constitutes a rescission of the prior assignment. Check only the Rescission box below if you want to rescind your prior assignment and receive direct payment with no assignment to an entity.
Assignment - I, the representative whose name appears in Section 2 and whose signature appears in Section 8, request any fee authorized to me in this claim be directly paid to the entity identified above in Part B. I understand that the entity to which I assign direct payment of my fee must be registered prior to this assignment. I also understand that I can rescind this assignment only prior to the date SSA notifies the claimant of the first favorable determination or decision. If I previously assigned direct payment to another entity, this assignment also constitutes a rescission of the prior assignment. Rescission of prior assignment - I, the representative whose name appears in Section 2 and whose signature appears in Section 8, rescind my prior assignment of direct payment of my authorized fee. Part D - Representative's Certifications
I accept this appointment and certify the following:
• I understand and agree that I will comply with the applicable policy and SSA rules on the representation of parties, including the Rules of conduct and standards of responsibility for representatives (20 CFR404.1-740-***-**** and 416.1-540-***-****); I will not charge, collect, or retain a fee for representational services that SSA has not approved or that is more than SSA approved unless a regulatory exclusion applies.
• I understand that if I fail to comply with any of applicable policy and SSA rules I may be suspended or disqualified from acting as a representative before SSA.
• I will not disclose any information to any unauthorized party without the claimant's specific written consent.
• I am not currently suspended or disqualified from practicing before the SSA.
• I am not prohibited from representing the claimant as a current or former officer or employee of the United States.
• I accept appointment as the representative for the claimant named in Section 1 of this form in connection with the claims and asserted rights described in Section 4 of this form.
• I agree that a copy of this signed form SSA-1696 will have the same force and effect as the original.
• I declare under penalty of perjury that I have examined all the information on this form and on all accompanying statements or forms, including any information, attestations and certifications provided to SSA in registration, and that they are all currently true and correct to the best of my knowledge.
I CERTIFY TO ALL OF THE ABOVE (Representative's Initials) Docusign Envelope ID: B50701B3-8580-4FCC-B865-550672CA04FF Form SSA-1696 (12-2024) UF Page 6 of 6
Claimant's Social Security Number
- -
Representative's Rep ID
Section 6 - Fee Arrangement (Representative Only)
Check one box below. If the representative is eligible for direct payment and this section is left unchecked, we will assume the representative will seek direct payment of a fee, until we receive a written waiver. I will request a fee and direct payment of this fee. Select this box if you are eligible for direct payment and want us to withhold a portion of the past-due benefits to directly pay the fee we may authorize. (We must authorize the fee.) I will request a fee but not direct payment. Select this box if you are not eligible for direct payment from the past-due benefits, or if you do not want direct payment. You are responsible for collecting any fee we may authorize on your own.
(We must authorize the fee.)
I waive the right to receive a fee from the claimant, any auxiliary beneficiaries or any other individual, but a third- party entity will pay my fee. Select this box if you certify that an entity, or a Federal, state, county, or city government agency will pay the fee and any expenses from its funds. The claimant, auxiliary beneficiaries, or other individuals must not be liable for the fee, directly or indirectly, in whole or in part, or any expenses. (We do not need to authorize the fee if all regulatory conditions apply.)
I waive the right to a fee.
Section 7 - Other Claimants
List below any auxiliary claimants, such as a child or spouse of the claimant or number holder, who have not appointed their own representative.
Social Security Number
- -
Name
- -
- -
- -
Section 8 - Signatures
Both you and your representative must sign this form if you are appointing a new representative. If you or your representative are submitting this form to update information relating to your existing appointment of this representative:
• You must sign this form if you are updating the information in Section 3.
• Your representative must sign this form if updating the information in Section 5.
• Both you and your representative must sign this form if updating the information in Sections 4, 6, or 7. Representative's Signature Date
Claimant's Signature Date
Docusign Envelope ID: B50701B3-8580-4FCC-B865-550672CA04FF Form SSA-1696 (12-2024) UF Page 6 of 6
Claimant's Social Security Number
- -
Representative's Rep ID
Section 6 - Fee Arrangement (Representative Only)
Check one box below. If the representative is eligible for direct payment and this section is left unchecked, we will assume the representative will seek direct payment of a fee, until we receive a written waiver. I will request a fee and direct payment of this fee. Select this box if you are eligible for direct payment and want us to withhold a portion of the past-due benefits to directly pay the fee we may authorize. (We must authorize the fee.) I will request a fee but not direct payment. Select this box if you are not eligible for direct payment from the past-due benefits, or if you do not want direct payment. You are responsible for collecting any fee we may authorize on your own.
(We must authorize the fee.)
I waive the right to receive a fee from the claimant, any auxiliary beneficiaries or any other individual, but a third- party entity will pay my fee. Select this box if you certify that an entity, or a Federal, state, county, or city government agency will pay the fee and any expenses from its funds. The claimant, auxiliary beneficiaries, or other individuals must not be liable for the fee, directly or indirectly, in whole or in part, or any expenses. (We do not need to authorize the fee if all regulatory conditions apply.)
I waive the right to a fee.
Section 7 - Other Claimants
List below any auxiliary claimants, such as a child or spouse of the claimant or number holder, who have not appointed their own representative.
Social Security Number
- -
Name
- -
- -
- -
Section 8 - Signatures
Both you and your representative must sign this form if you are appointing a new representative. If you or your representative are submitting this form to update information relating to your existing appointment of this representative:
• You must sign this form if you are updating the information in Section 3.
• Your representative must sign this form if updating the information in Section 5.
• Both you and your representative must sign this form if updating the information in Sections 4, 6, or 7. Representative's Signature Date
Claimant's Signature Date
Docusign Envelope ID: B50701B3-8580-4FCC-B865-550672CA04FF Z M 9 J P X 5 9 Z H
Alexander A Sioutis
255 Great Valley Pkwy
Ste 150
Malvern
PA 19355
Docusign Envelope ID: B50701B3-8580-4FCC-B865-550672CA04FF x
Z M 9 J P X 5 9 Z H
I understand that my representative may still request a fee even if my case does not result in past-due benefits. If the fee agreement cannot be approved because there are no past-due benefits or for other reasons, my representative may file a fee petition to request that SSA authorize a fee. I also understand that if there are no past- due benefits withheld, if not enough past-due benefits are withheld, or if my representative is not eligible for direct payment by SSA, I will be responsible to pay the authorized fee to my representative(s) directly. SSA does not authorize out-of-pocket costs and expenses which I am responsible for paying directly to my representative. Docusign Envelope ID: B50701B3-8580-4FCC-B865-550672CA04FF Z M 9 J P X 5 9 Z H
Docusign Envelope ID: B50701B3-8580-4FCC-B865-550672CA04FF Form SSA-827 (06-2024) UF
Discontinue Prior Editions
Page 1 of 2
OMB No. 0960-0623
Whose Records to be Disclosed
NAME (First, Middle, Last, Suffix)
SSN Birthday (MM/DD/YYYY)
AUTHORIZATION TO DISCLOSE INFORMATION TO
THE SOCIAL SECURITY ADMINISTRATION (SSA)
** PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW ** I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange): All my medical records: also education records and other information related to my ability to perform tasks. This includes Specific permission to release:
1. All records and other information regarding my treatment, hospitalization, 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 noncommunicable disease; and tests for or records of HIV/AIDS
• Gene-related impairments (including genetic test results) 2. Information about how my impairment(s) affects my ability to complete 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. Information created within 12 months after the date this authorization is signed, as well as past information. FROM WHOM
• All medical sources (hospitals, clinics, labs,
physicians, psychologists, etc.) including mental
health, correctional, addiction treatment, and VA
health care facilities
• All educational sources (schools, teachers, records administrators, counselors, etc.)
• Social workers/rehabilitation counselors
• Consulting examiners used by SSA
• Employers, insurance companies, workers'
compensation programs
• Others who may know about my condition (family,
neighbors, friends, public officials)
THIS BOX TO BE COMPLETED BY SSA/DDS (as needed). Additional information to identify the subject (e.g., other names used), the specific source, or the material to be disclosed: TO WHOM 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.] PURPOSE Determining my eligibility for benefits, including looking at the combined effect of any impairments that by themselves would not meet SSA's definition of disability; and whether I can manage such benefits. Determining whether I am capable of managing benefits ONLY (check only if this applies) EXPIRES WHEN This authorization is good for 12 months from the date signed (below my signature).
• I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above.
• I understand that there are some circumstances in which this information may be redisclosed to other parties (see page 2 for details).
• I may write to SSA and my sources to revoke this authorization at any time (see page 2 for details).
• SSA will give me a copy of this form if I ask; I may ask the source to allow me to inspect or get a copy of material to be disclosed.
• I have read both pages of this form and agree to the disclosures above from the types of sources listed. PLEASE SIGN USING BLUE OR BLACK INK ONLY
INDIVIDUAL authorizing disclosure - Signature
IF not signed by subject of disclosure, specify basis for authority to sign Parent of minor
Guardian
Other personal
representative (explain)
(Parent/guardian/personal representative sign
here if two signatures required by State law)
Date Signed Street Address
Phone Number (with area code) City State ZIP
WITNESS I know the person signing this form or am satisfied of this person's identity: Signature
Phone Number (or Address)
IF needed, second witness sign here (e.g., if signed with "X" above) Phone Number (or Address)
This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical, educational, and other information under P.L. 104-191 ("HIPAA"); 45 CFR parts 160 and 164; 42 U.S. Code section 290dd-2; 42 CFR part 2; 38 U.S. Code section 7332; 38 CFR 1.475; 20 U.S. Code section 1232g ("FERPA"); 34 CFR parts 99 and 300; and State law. OF WHAT
Docusign Envelope ID: B50701B3-8580-4FCC-B865-550672CA04FF Jose Luis Sanchez
Claimant/Patient:
AUTHORIZATION
I hereby authorize use or disclosure of protected health information, employment information, or other personal information about me as described below for Social Security purposes. 1. The following specific person or class of persons or facility is authorized to make the requested use or disclosure: 2. The following person or class of persons may receive disclosure of protected health information about me:
Victory Disability, LLC
255 Great Valley Pkwy. Ste 150
Malvern, PA 19355
(P) 866-***-****
(F) 866-***-****
********@*******-**********.***
3. The specific information that should be disclosed is: all medical and mental health records, including sensitive information .
4. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.
5. I hereby discharge the releasing facility, its agents and employees, from any and all liabilities, responsibilities, damages, and claims which might arise from the release of authorization herein, to include alcohol, drug abuse, communicable disease including HIV status, and/or psychiatric diagnoses compiled during my visit, encounter, or hospitalization, or make copies thereof in accordance with the policies of this facility.
6. l may revoke this authorization by notifying the facility in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. l understand that the entity to whom this authorization is furnished may not condition its treatment of me, or payment, on whether or not I sign the authorization.
7. This authorization expires on,, OR one year after the date signed below, OR upon occurrence of the following event that relates to me or to the purpose of the intended use or disclosure of information about me: Social Security Determination. 8. Purpose of Disclosure: Social Security Purposes X Signature of Individual or Representative Date
Date of Birth Social Security Number
Docusign Envelope ID: B50701B3-8580-4FCC-B865-550672CA04FF Jose Luis Sanchez
ADMINISTRATIVE RECORDS:
VA FORM 10-5345
OCT 2023
Page 1 of 2
LAST NAME- FIRST NAME- MIDDLE NAME
The information requested on this form is solicited under Title 38 U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S.C. 552a; and 38 U.S.C. 5701 and 7332 that you specify. Your disclosure of the information requested on this form is voluntary. However, if information needed to locate records for release is not furnished completely and accurately, VA will be unable to comply with the request. The Veterans Health Administration may not condition the provision of treatment, payment, enrollment in the VA Health Care Program, or eligibility for benefits on the signing of an authorization, except for research-related treatment where an authorization for the use or disclosure of individually- identifiable health information for such research is required. VA may disclose the information that you put on the form as permitted by law. VA may make a
"routine use" disclosure of the information as outlined in the Privacy Act system of records notices identified as 24VA10A7 "Patient Medical Record - VA", 08VA05 "Employee Medical File System Records (Title 38)-VA" and in accordance with the Notice of Privacy Practices. VA may also use this information to identify Veterans and person claiming or receiving VA benefits and their records, and for other purposes authorized or required by law. REQUEST FOR AND AUTHORIZATION TO
RELEASE HEALTH INFORMATION
HEALTH SUMMARY (Prior 2 Years)
LIST OF ACTIVE MEDICATIONS:
RADIOLOGY REPORTS (Name & Date):
DATE RANGE:
SPECIFIC TESTS (Name & Date):
LAB RESULTS:
OPERATIVE/CLINICAL PROCEDURES (Name & Date):
DATE RANGE:
SPECIFIC PROVIDERS (Name & Date Range):
SPECIFIC CLINICS (Name & Date Range):
PROGRESS NOTES:
INPATIENT DISCHARGE SUMMARY (Dates):
TO: DEPARTMENT OF VETERANS AFFAIRS (Name and Location of the VA Health Care Facility) NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL, OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED PATIENT'S MAILING ADDRESS (including City, State and Zip Code) PATIENT MEDICAL RECORDS (Dates):
VACCINATION (Dose, Lot Number, Date & Location):
DATE OF BIRTH (mm/dd/yyyy)
INFORMATION REQUESTED: Check applicable box(es) and state the extent or nature of information to be provided: TREATMENT BENEFITS LEGAL EMPLOYMENT
PURPOSE(S) OR NEED: Information is to be used by the requestor for: OTHER (Describe):
OTHER (Please specify below):
PRIVACY ACT STATEMENT:
Social Security Claim
All medical and mental treatment records from
All medical and mental treatment records from
All medical & mental records from all VA clinics/centers from All operative and procedure reports form
All X-rays, MRIs, CTs, ultrasounds, etc from
Docusign Envelope ID: B50701B3-8580-4FCC-B865-550672CA04FF Sanchez Jose
FOR VA USE ONLY
PATIENT SIGNATURE (Sign in ink) DATE (mm/dd/yyyy)
AFTER ONE-TIME DISCLOSURE, IF ALL NEEDS ARE SATISFIED ON (mm/dd/yyyy)
I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon receipt by the Release of Information Unit at the facility housing records. Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules. I understand that the VA health care provider's opinions and statements are not official VA decisions regarding whether I will receive other VA benefits or, if I receive VA benefits, their amount. They may, however, be considered with other evidence when these decisions are made at a VA Regional Office that specializes in benefit decisions. EXPIRATION: Without my express revocation, the authorization will automatically expire (select one of the following):
(enter a future date other than date signed by patient) LEGAL REPRESENTATIVE SIGNATURE (if applicable) (Sign in ink) DATE (mm/dd/yyyy) PRINT NAME OF LEGAL REPRESENTATIVE RELATIONSHIP TO PATIENT TYPE AND EXTENT OF MATERIAL RELEASED
DATE RELEASED (mm/dd/yyyy) RELEASED BY:
LAST NAME- FIRST NAME- MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy) VA FORM 10-5345, OCT 2023 Page 2 of 2
I understand that information on these sensitive diagnoses may be released for treatment purposes without me checking the above boxes, and will be released even if the boxes are unchecked unless I indicate by checking the box below that I do not want this information released for this specific disclosure.
SENSITIVE DIAGNOSES: REVIEW AND, IF APPROPRIATE, COMPLETE WHEN RELEASE IS FOR ANY PURPOSE OTHER THAN TREATMENT.
DRUG ABUSE ALCOHOLISM OR ALCOHOL ABUSE SICKLE CELL ANEMIA I do not want sensitive diagnoses released for treatment purposes under this specific authorization. I realize this does not impact other future requests unrelated to this authorization. HUMAN IMMUNODEFICIENCY VIRUS (HIV)
UNDER THE FOLLOWING CONDITION(S):
I request and authorize Department of Veterans Affairs to release the information pertaining to the condition(s) below for the non-treatment purpose(s) listed in this authorization.
AUTHORIZATION:
2 years from the date of patient's signature
Docusign Envelope ID: B50701B3-8580-4FCC-B865-550672CA04FF