I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange):

To be completed by Retirement Systems/Disability Determination Service

Relationship to applicant:

AUTHORIZATION FOR RELEASE OF INFORMATION

SC Public Employee Benefit Authority

South Carolina Retirement Systems

P.O. Box 11960, Columbia, SC 29211-1960

Signature of Applicant or Guardian/Power of Attorney:

State:

Street Address:

City:

State:

Zip + 4:

The signature and the address of a person who either knows the person signing this form or is satisfied as to that person's identity are requested below.  Although not required by South Carolina Retirement Systems, a provider might not honor this authorization without the signature and address of a witness.

Signature of Witness:

City:

Applicant/Patient number:

Return completed form to the SC Retirement Systems (see address above)
Please contact Customer Services with any questions: 803-737-6800, 800-868-9002 (within SC only) or  www.retirement.sc.gov

Zip + 4:

Name and address of applicant at time services were provided (if known--include zip code):

Name and address of provider (include zip code):

SECTION I

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.

SECTION II

Date of Birth:

TO WHOM-  The SC Retirement Systems and the agency authorized to process my case (usually called 'disability determination  service'), including contract copy services, and doctors or other professionals consulted during the process.  Records may also be provided to the Social Security Administration, if necessary.

PURPOSE- Determining my eligibility for benefits, including looking at the combined effect of my impairments that by themselves would not 

meet SC Retirement Systems' definition of disability.

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 where this information may be redisclosed to other parties (see Page 2 for details).

      -I may write to SC Retirement Systems and my sources to revoke this authorization at any time (see Page 2 for details).

      -SC Retirement Systems 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.

OF WHAT-  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 

     --Human immunodeficiency virus (HIV) infection (including acquired immunodeficiency syndrome (AIDS) or tests for HIV) or sexually transmitted diseases.

     --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 ability to work.

3.  Copies of educational tests or evaluations, including individualized Educational Programs, triennnial 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.

      -Social workers/rehabilitation counselors                  

      -All educational sources (schools, teachers, records administrators, counselors, etc.)

      -Employers

      -Consulting examiners used by the SC Retirement Systems/DDS

      -Others who may know about my condition (family, neighbors, friends, public officials)

To be completed by applicant or person authorized to act on his/her behalf

Form 6255
Revised 6/3/2016

Page 1

Please complete form

in blue or black ink.

Applicant Last Name:

Suffix: