Current SSA-9310

Social Security Administration
Office of Quality Review
(Address of Office)
Date:
Beneficiary Name:
SSN:

(Address)

On (fill-in 1), I spoke with you regarding the review of (fill-in 2). In order to proceed with
the review, the following is needed:

(fill-in 3)

Please send the requested documents in the enclosed self-addressed, postage-paid
envelope. We will return your documents immediately.
If you have questions about this request, contact me at 1-800-______ between 8:00 a.m.
and 4:00 p.m., Monday through Friday.
Thank you for your cooperation.

Sincerely,

Social Insurance Specialist

Enclosure(s)

Request for Documents
SSA-9310 (Rev 11-2014)

PRIVACY ACT AND PAPER REDUCTION ACT NOTICE
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 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 this information to others, called routine uses, is available
in our Privacy Act Systems 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.

Paperwork Reduction Act Statement – This information collection meets the requirements
of 44 U.S.C §section 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 for this collection
is 0960-0707. We estimate that it will take 5 minutes to read the instructions, gather the
facts, and answer the questions. Send only comments on our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.

Request for Documents
SSA-9310 (Rev 11-2014)