Information Collection

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

IC 216301 under ICR 201805-0960-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Privacy Act Statement (revised).doc	Other-Privacy Act Statement (revised
SSA-8510 Authorization for the Social Security Administration to ssa-8510 (revised).pdf	Form
ssa-8510 (current).pdf SSA-8510 (current)	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.203 20 CFR 404.1926 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 (revised).pdf		No		Paper Only
Other-Privacy Act Statement (revised)			Privacy Act Statement (revised).doc		No		Printable 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	Previously Approved
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
SSA-8510 (current)	ssa-8510 (current).pdf	05/21/2018

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