Appeal Of Determination Page 4
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4Privacy Act Statement
Collection and Use of Personal Information
Section 1860 D-14 of the Social Security Act, as amended, allows us to collect this information.
We will use the information you provide to determine your eligibility for help paying your share of
the cost of a Medicare Prescription Drug Plan.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
requested information could prevent an accurate and timely decision on your appeal.
We rarely use the information you supply for any purpose other than for making a determination
about your continuing entitlement to benefits. However, we may use the information for the
administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans’ Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
private concerns under contract to Social Security).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0321, entitled Medicare Database.
Additional information about this and other system of records notices and our programs are
available from our Internet website at
or at your local Social Security
office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
— This information collection meets the requirements of
Paperwork Reduction Act Statement
44 U.S.C. §3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take about 10 minutes to read the instructions, gather the
facts, and answer the questions. You may send comments on our time estimate above to: Social
Security Administration, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address, not the completed form.
Form SSA-1021 (07-2014)
Page 4
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