Information Collection

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

IC 216301 under ICR 202105-0960-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form SSA-8510 Authorization for the Social Security Administration to Obtain Personal Information SSA-8510 – Medicare Subsidy Quality Review (paper version)	Form
Privacy Act Statement (revised).doc	Other-Privacy Act Statement (revised
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 Authorization for the Social Security Administration to ssa-8510 (revised).pdf	Form
ssa-8510 (current).pdf SSA-8510 (current)	IC Document
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: Removed

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1926 20 CFR 404.704 20 CFR 404.820 - 404.823 20 CFR 418.3001 20 CFR 416.203

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				No		Paper Only
Other-Privacy Act Statement (revised)					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
	Change Due to Adjustment in Agency Estimate	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)		05/21/2018

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].