Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)

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

Section 1860D-14 of the Social Security Act, as amended, allows 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 making a decision on your eligibility for a Medicare Part D
subsidy.
We will use the information to obtain income and resource information to determine if you are
eligible for a Medicare Part D subsidy. We may also share your information for the following
purposes, called routine uses:
1. To applicants, claimants, prospective applicants or claimants (other than the data subjects
and their authorized representatives) to the extent necessary for the purpose of pursuing
Medicare Part D and Part D subsidy entitlement or appeal rights; and
2. To Federal, State, or local agencies (or agents on their behalf) for administering income
maintenance or health maintenance programs (including programs under the Social
Security Act).
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
(SORN) 60-0090, entitled Master Beneficiary Record; and 60-0321, entitled Medicare Database
File. Additional information and a full listing of all our SORNs are available on our website at
https://www.ssa.gov/privacy/sorn.html.