Form SSA-9314 Notice of Quality Review Acknowledgement Form for those

Social Security Administration
Office of Quality Performance Review
(Address of Office)
Date:
Beneficiary Name:
SSN:
(Address)
The Social Security Administration is contacting a few people who had a recent
redetermination of their extra help with Medicare prescription drug plan costs. We are
doing a quality review to make sure we made the correct decision on these
redeterminations. We picked (fill-in 1) name by chance, NOT for any other reason. To
make sure we made the correct decision on (fill-in 2) redetermination, I would like you
to telephone me at my office on (fill-in 3). For general information about Social Security
or to verify that this is an official communication, you can call our national toll-free
number at 1-800-772-1213.
IMPORTANT INFORMATION
You do not have to give us the requested information. If you do provide the information
and your subsidy level is correct, we will not have to contact you to review your eligibility
for at least another year unless you report a subsequent change in your income,
resources or household size. However, if the information is incorrect or you do not
provide the information, we may contact you to review your eligibility within the next few
months. Such review of your eligibility could result in your subsidy level increasing,
decreasing or stopping. The Social Security law that allows us to ask you questions is
explained in the enclosed page, Privacy Act and the Paper Reduction Act Notice.
Your cooperation with this review will help us to ensure the process for helping
Medicare beneficiaries with their prescription drug costs is providing the correct help to
the correct people.
We would also like to remind you that if you (and your spouse if married and living
together) have a change in your income, resources or household size, you should report
this information to Social Security.
WHAT WILL HAPPEN WHEN YOU CALL
I will identify myself by name as shown at the bottom of this letter. I will ask you some
questions about the information on (fill-in 4) recent redetermination of the extra help
with Medicare prescription drug plan costs.
HOW YOU CAN GET READY FOR YOUR CALL
I have enclosed a page that shows the kinds of information you should have ready. I
have checked the things I would like to talk about. If you do not have all of the
information that I am requesting, I can help you get the information you do not have. If
Notice of Appointment-Redetermination–Please Call Reviewer
SSA-9314 (2-2012)

you would like to have a friend or relative help you, please tell that person to be there
when you call.
PLEASE RETURN THE ENCLOSED FORM
I have enclosed an acknowledgement form for you to complete, sign and mail
back to me in the envelope I have provided. You do not need to put a stamp on
the envelope. This form is to let me know you received this letter and whether or
not you will be able to call me.
If you have any questions, please call me at my office between 8:00 a.m. and 4:00 p.m.,
Monday through Friday. My toll-free number is 1-800- ______. Thank you for your help.
Sincerely,

Social Insurance Specialist
Enclosures

Notice of Appointment-Redetermination-Please Call Reviewer
SSA-9314 (2-2012)

PRIVACY ACT AND PAPER REDUCTION ACT NOTICE
COLLECTION AND USE OF INFORMATION
Section 1860 D-14 of the Social Security Act, as amended, authorizes us to collect the
information contained on this form. We will use the information you provide us to determine
your eligibility to the Medicare prescription drug plan. Your responses are voluntary. However,
failure to provide all or part of the requested information may affect the processing of this form
and could prevent us from making an accurate and timely decision regarding your eligibility and
your appeal rights.
HOW THE INFORMATION IS USED
We rarely use the information provided on this form for any other purpose than the reasons
explained above. However, we may use it for the administration and integrity of Social Security
programs. We may also discloseSee
information
revised to another person or to another agency in
accordance with approved routine uses, which include, but are not limited to the following:

Privacy Act
below.
1. To enable a third partyStatement
or an agency
to assist Social Security in establishing rights to
Social Security benefits and/or coverage;

2. To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office and the Department of Veterans’
Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit and investigative activities necessary to ensure
the integrity of Social Security programs.
We may also use the information you provided in computer matching programs. Matching
programs compare our records with records kept by other Federal, State and local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for Federally funded or administered benefit programs and for repayment of
payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Records Notice,
entitled, Medicare Database (MDB) File, 60-0321. The notice, additional information regarding
this form, and information regarding our programs and systems, are available on-line
at www.socialsecurity.gov or at your local Social Security office.
Paperwork Reduction Act Statement – This information collection meets the requirements of 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 (OMB) control number. The OMB
control number of this collection is 0960-0707. We estimate that it will take 15 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.

Notice of Appointment-Redetermination–Please Call Reviewer
SSA-9314 (2-2012)

FORM APPROVED
OMB No. 0960-0707

ACKNOWLEDGEMENT FORM
(RETURN THIS SHEET IMMEDIATELY)
_________________________________________________________________________________

_______________________

Beneficiary’s Name

Beneficiary’s SSN

1. Will you be available at the time requested? □ Yes

□ No

2. What telephone number can we use to reach you, including area code?
( )____________________
3. If you will not be available at the time requested, we can reschedule your appointment. If you would
like to reschedule, please let us know when you will be available at that number.
_______________________________________________________________________________
4. Is your address shown correctly on this letter? □ Yes □ No
If “NO”, please show the appropriate address below:
_______________________________________________________________________________
_______________________________________________________________________________
5. If you need assistance with the telephone interview due to a hearing impairment, please
check/complete the appropriate box(es) shown below:
□ I am deaf or hard of hearing. I will have a person to assist me with this telephone interview.
His/her name is _____________________. He/she is my __________________ (indicate
your relationship).
□ I am deaf or hard of hearing. SSA may call me with the assistance of a Telephone State
Relay System operator.
6. If you need assistance with the telephone interview due to language problems, please
check and complete the appropriate box(es) shown below:
□ I need a language interpreter. I speak__________________ (indicate language).
□ I will provide a qualified language interpreter for this telephone interview. His/her name is
_____________________. He/she is my __________________ (indicate your relationship).
(Your interpreter should be 18 years of age or older).
□ I want SSA to provide a qualified language interpreter for this phone interview at no cost to
me.

Sign
here

►

____________________________________________________________________

______________________

(SIGNATURE of Beneficiary or Payee if applicable)

Date
QRA_______________________

Notice of Appointment-Redetermination–Please Call Reviewer
SSA-9314 (2-2012)

Privacy Act Statement
Collection and Use of Personal Information

Section 1860 D-14 of the Social Security Act of the Social Security Act, as amended, allows us
to collect this information. We will use the information you provide to determine your continued
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
information could result in a change or termination of your subsidy.
We rarely use the information you supply for any purpose other than what we state above,
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);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
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 www.socialsecurity.gov 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.