Form SSA-9310 Request for Documents

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

(Address)

On (fill-in 1), we 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 us at 1-800and 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)

between 8:00 a.m.

PRIVACY ACT AND PAPER REDUCTION ACT NOTICE
Privacy Act Statement
Collection and Use of Personal Information

See Revised
Privacy Act
Statement
Section 1860D-14A 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 evaluating the denial of your Medicare Part D subsidy request.
We will use the information to make a determination of eligibility or continued eligibility for
benefits. We may also share your information for the following purposes, called routine uses:
1. To the Centers for Medicare & Medicare Services, for the purpose of administering
Medicare Part D enrollment and premium collection and Medicare Advantage Part C
premium collections, as well as Medicare Part B income-related monthly adjustment
amounts; and
2. To Federal and State agencies administering Medicare Part D and Part D subsidy under
the Medicare Prescription Drug Improvement and Modernization Act of 2003.
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 Notice
(SORN) 60-0321, entitled Medicare Database File. Additional information and a full listing of
all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.
Paperwork Reduction Act Statement - This information collection meets the requirements
of 44 U.S.C. § 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. We estimate that it will take about 5 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments relating to our
time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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

Privacy Act Statement
Collection and Use of Personal Information
Section 1860D-14(a) 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 evaluating your Medicare Part D subsidy request.
We will use the information to make a determination of eligibility or continued eligibility for
benefits. We may also share your information for the following purposes, called routine uses:
1. To the Centers for Medicare & Medicaid Services, for the purpose of administering
Medicare Part D enrollment and premium collection and Medicare Advantage Part C
premium collections, as well as Medicare Part B income-related monthly adjustment
amounts; and
2. To Federal and State agencies administering Medicare Part D and Part D subsidy under
the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
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 Notice
(SORN) 60-0321, entitled Medicare Database File (MDB File), as published in the Federal
Register (FR) on July 25, 2006 at 71 FR 42159. Additional information and a full listing of all
of our SORNs is available on our website at www.ssa.gov/privacy.