Information Collection

SSA-8510 – Medicare Subsidy Quality Review (paper version)

IC 216301 under ICR 201504-0960-011 · OMB 0960-0801.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0801 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8510 SSA-8510 – Medicare Subsidy Quality Review (paper version)	Form
SSA-8510 Authorization for the Social Security Administration to SSA-8510.pdf	Form

IC Title:

SSA-8510 â Medicare Subsidy Quality Review (paper version)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1926 20 CFR 416.203 20 CFR 404.704 20 CFR 404.820 - 404.823 20 CFR 418.3001

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-8510	Authorization for the Social Security Administration to Obtain Personal Information	SSA-8510.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	292	292
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.