Request for Reconsideration--Paper and MCS/MSSICS

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205, 702(a)(5), 809(a), 809(b), 1631, 1633, and 1869(b) allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent us from re-evaluating the decision on your claim.
We will use the information to determine your eligibility for benefits and administer our
programs. We may also share your information for the following purposes, called routine uses:
1. To third party contacts in situations where the party to be contacted has, or is expected to
have, information relating to the individual’s capability to manage his/her affairs or
his/her eligibility for or entitlement to benefits under the Social Security program.
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration in the efficient administration of its programs.
3. To the Center for Medicare & Medicaid Services (CMS), for the purpose of
administering Medicare Part A, Part B, Medicare Advantage Part C, and Medicare Part
D, including but not limited to: Medicare Part C enrollment and premium collection
processes; Part D enrollment and premium collection processes; Medicare Part B
premium reduction based on participation in a Part C plan; and Medicare Part B
enrollment and income-related monthly adjustment amount determinations, appeals of
determinations, and premium collections.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORNs). There are several SORNs that govern the collection of this information, including 600089, entitled Claims Folder System, and 60-0321, entitled Medicare Database File. Additional
information and a full listing of all our SORNs and applicable routine uses are available on our
website at www.socialsecurity.gov/foia/bluebook.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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. We estimate that it will take about 8
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.