SSA-1021 Appeal of Determination for Help with Medicare Prescript

Form Approved
OMB No. 0960-0695

Appeal of Determination for
Extra Help with Medicare
Prescription Drug Plan Costs
1.

FOR OFFICIAL USE ONLY
Date received:
Office code:

Request filed late:

Applicant’s Name:

2. Social Security Number:

3. Medicare Number (if different from Social Security number):

4. Spouse’s Name (if spouse lives at same address as you):
5. Spouse’s Social Security Number (if spouse lives at same address as you):
6. Spouse’s Medicare Number (if different from spouse’s Social Security number and spouse lives at
same address as you):
7. Please explain why you disagree with our decision:

8. Do you have additional information to support your appeal?
YES Send the additional information with this form to the address shown on the bottom
of page 2.
NO
9. Do you want a hearing? If you have a hearing, it will be by telephone.
YES You will receive a notice with the date and time of the hearing. Please complete
questions 10 through 13.
NO You will receive a decision based on the information available and any
additional information you provide.
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10. To give you time to prepare for the hearing, we must allow at least 20 days between the date
of your request and the date we schedule the hearing. Do you want a hearing sooner if
scheduling permits?
YES
NO
11. Do you need an interpreter?
YES
NO
12. Are you hearing impaired?
YES
NO
13. Will you have other people at the hearing?
YES
NO
If YES, will you and the other people need to talk to us from more than one telephone number?
YES We call this a conference call. When we send you the notice scheduling the hearing,
we will give you a telephone number to use for this conference call and additional
instructions for setting up this call.
NO

Please return your completed appeal form, including the signature page, and any additional
information to:
Social Security Administration
Wilkes-Barre Direct Operations Center
P.O. Box 1030
Wilkes-Barre, PA 18767-1030
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Signatures
I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true to the best of my knowledge. I understand that making a
false statement is a crime punishable under Federal law. By submitting this appeal, I am authorizing the
Social Security Administration to obtain and disclose information related to my income, resources and
assets, foreign and domestic, consistent with applicable privacy laws. This information may include, but is
not limited to, information about my wages, account balances, investments, benefits, and pensions. Please
complete Section A. If you cannot sign, a representative may sign for you. If someone assisted you,
complete Section B as well.

SECTION A

Your Signature:
Your Home Street Address:
City:

Phone Number:
(
)
Apt. #:
State:

Your Mailing Street Address (if different from home address):
City:

ZIP Code:
Apt. #:

State:

ZIP Code:

If you recently changed your address, put an X here:
If you would prefer that we contact someone else if we have additional questions, please provide the
person’s name and a daytime phone number.
Print Last Name:

Print First Name:

Phone Number:
(
)

SECTION B
If someone assisted you, place an X in the box that describes that person and provide the rest of the
information requested below.
Family Member

Attorney

Advocate

Friend

Agency

Social Worker

Print First Name:

Print Last Name:

Other
Specify:
_______________
______________________
Phone Number:
(
)

Address:

Apt. #:
State:

City:
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ZIP Code:

Privacy Act / Paperwork Reduction Notice
Section 1860 D-14 of the Social Security Act, as amended, authorizes us to collect this
information. The information you provide will be used to determine if you are eligible for help
paying your share of the cost of a Medicare Prescription Drug Plan.
The information you furnish on this form is voluntary. However, failure to provide this
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 it for the administration and
integrity of Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not limited to the
following:
See Revised Privacy Act Statement Attached
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefi ts and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Offi ce and 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, or investigative activities necessary to assure
the integrity and improvement of Social Security programs (e.g., to the Bureau of the
Census and private concerns under contract to Social Security).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or 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 our System of Records
Notice entitled Medicare Database (60-0321). This 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
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.

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