Consent for Release of Information, Form SSA-3288.
SSA 3288 Consent for Release of InformationSeptember 30, 2018
SSA 2459 BPQYSeptember 30, 2018
Benefits Planning Query (BPQY), Form SSA-2459
The Benefits Planning Query (BPQY) is part of the Social Security Administration’s (SSA) efforts to inform Social Security Disability Insurance (SSDI) beneficiaries and Supplemental Security Income (SSI) recipients about their disability benefits and the use of the work incentives.
- Cash Benefits – For both SSDI and SSI shows the Type of Benefit, Current Status, Statutory Blindness, Date of Entitlement, Full Amount, Net Amount, Others Paid on This Record, Total Family Cash Benefit, Overpayment Balance, and Monthly Amount Withheld.
- Health Insurance – Shows Medicare or Medicaid eligibility, and for Medicare (both Part A Hospital and Part B Medical) the date of coverage, premium amounts, and State Premium Buy-In.
- Medical Reviews – For both SSDI and SSI, shows the Next Scheduled Medical Review, the Medical Re-Exam Schedule, and if deferred due to the Ticket to Work Program.
- Representation – For both SSDI and SSI, indicates whether you currently have a Representative Payee or Authorized Representative.
- SSDI Work Activity – Shows Trial Work Period months start date, end date, and months used, month of cessation, and current SGA level.
- SSI Work Exclusions – Identifies any of the SSI work incentives that exclude earned income, with dates and dollar amounts, including Blind Work Expenses (BWE), Impairment Related Work
- Expenses (IRWE), Student Earned Income Exclusions (SEIE), and PASS Exclusion.
- Recent Earnings on Record – Shows all lifetime yearly work earnings from wages and self-employment, as well as monthly earnings for the most recent two years.
Who would request this planning tool and how it is used?
- This form is generally requested by Employment Networks (ENs) and the State Vocational Rehabilitation (VR) agencies.
- It is used to verify:
- The type and amount of Social Security disability benefits(s) received;
- Medicare and medicaid information; and
- Information about past work and work incentive usage.
To obtain a copy of BPQY, either call Social Security Administration or contact us.
- Two signed Consent for Release of Information, Form SSA-3288, must be submitted to Social Security if the BPQY will be sent to anyone other than the beneficiary and/or representative payee.
- The SSA-3288s should be pre-filled with recommended language for release of Social Security and Internal Revenue Service records – refer to BPQY handbook.
Physical Residual Functional Capacity Assessment, SSA-4734January 28, 2017
The RFC form (SSA-4734) is the Physical Residual Functional Capacity Assessment form that helps the Social Security Administration rate the functional capacity of a Social Security Disability claimant after considering one’s mental or physical disability into account, including:
- Range of motion
- Physical strength
- Lifting ability
- Stamina and ability to carry objects
- Other abilities required for their job