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

Authorization for the Social Security Administration to Obtain Personal Information

Documents and Forms

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

Information Collection (IC) Details

IC Title:	SSA-8510 – 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:

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 %

	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

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.