Form SSA-9314 Notice of Quality Review Acknowledgement Form for those

Social Security Administration
Office of Quality Review
(Address of Office)
Date:
Beneficiary Name:
SSN:
(Address)
The Social Security Administration is contacting a few people who had a recent
redetermination of their extra help with Medicare prescription drug plan costs. We are
doing a quality review to make sure we made the correct decision on these
redeterminations. We picked (fill-in 1) name by chance, NOT for any other reason. To
make sure we made the correct decision on (fill-in 2) redetermination, we would like
you to telephone us at our office on (fill-in 3).
To verify that this is an official communication, or for general information about Social
Security, you can call our national toll-free number at 1-800-772-1213.
IMPORTANT INFORMATION
You do not have to give us the requested information. If you do provide the information
and your subsidy level is correct, we will not have to contact you to review your eligibility
for at least another year unless you report a subsequent change in your income,
resources, or household size. However, if the information is incorrect or you do not
provide the information, we may contact you to review your eligibility within the next few
months. Such review of your eligibility could result in your subsidy level increasing,
decreasing, or stopping. The Social Security law that allows us to ask you questions is
explained in the enclosed page, Privacy Act and the Paper Reduction Act Notice.
Your cooperation with this review will help us to ensure the process for helping
Medicare beneficiaries with their prescription drug costs is providing the correct help to
the correct people.
We would also like to remind you that if you (and your spouse if married and living
together) have a change in your income, resources, or household size, you should
report this information to Social Security.

Notice of Appointment-Redetermination–Please Call Reviewer
SSA-9314 (Rev 05-2023)

WHAT WILL HAPPEN WHEN YOU CALL
We will identify ourselves by name as shown at the bottom of this letter. We will ask
you some questions about the information on (fill-in 4) recent redetermination of the
extra help with Medicare prescription drug plan costs.
HOW YOU CAN GET READY FOR YOUR CALL
We have enclosed a page that shows the kinds of information you should have ready.
We have checked the things we would like to talk about. If you do not have all of the
information that we are requesting, we can help you get the information you do not
have. If you would like to have a friend or relative help you, please tell that person to be
there when you call.
PLEASE RETURN THE ENCLOSED FORM
We have enclosed an acknowledgment form for you to complete, sign and mail
back to us in the envelope we have provided. You do not need to put a stamp on
the envelope. This form is to let us know you received this letter and whether or
not you will be able to call us.
If you have any questions, please call us at our office between 8:00 a.m. and 4:00 p.m.,
Monday through Friday. Our toll-free number is 1-800. Thank you for your
help.
Sincerely,

Social Insurance Specialist
Enclosures

Notice of Appointment-Redetermination-Please Call Reviewer
SSA-9314 (Rev 05-2023)

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 result in SSA’s inability to schedule an interview.
We will use the information to document your availability for an interview. 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.
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 15 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.

Notice of Appointment-Redetermination–Please Call Reviewer
SSA-9314 (Rev 05-2023)

FORM APPROVED OMB
No. 0960-0707

ACKNOWLEDGMENT FORM
(RETURN THIS SHEET IMMEDIATELY)

Beneficiary’s Name

Beneficiary’s SSN

1. Will you be available at the time requested? □ Yes □ No
2. What telephone number can we use to reach you, including area code?
( )
3. If you will not be available at the time requested, we can reschedule your appointment. If you would
like to reschedule, please let us know when you will be available at that number.
_
4. Is your address shown correctly on this letter? □ Yes □ No
If “NO,” please show the appropriate address below:

5. If you need assistance with the telephone interview due to a hearing impairment, please
check/complete the appropriate box(es) shown below:
□ I am deaf or hard of hearing. I will have a person to assist me with this telephone interview.
His/her name is
. He/she is my
(indicate
your relationship).
□ I am deaf or hard of hearing. SSA may call me with the assistance of a Telephone State
Relay System operator.
6. If you need assistance with the telephone interview due to language problems, please
check and complete the appropriate box(es) shown below:
□ I need a language interpreter. I speak
(indicate language).
□ I will provide a qualified language interpreter for this telephone interview. His/her name is
. He/she is my
(indicate your relationship).
(Your interpreter should be 18 years of age or older).
□ I want SSA to provide a qualified language interpreter for this phone interview at no cost to
me.
Sign
here

►

(SIGNATURE of Beneficiary or Payee if applicable)

Date
QRA

Notice of Appointment-Redetermination–Please Call Reviewer
SSA-9314 (Rev 05-2023)