SSA-1021 Appeal of Determination for Help with Medicare Prescript

Form Approved
OMB No. 0960-0695

Appeal of Determination for
Extra Help with Medicare
Prescription Drug Plan Costs

FOR OFFICIAL USE ONLY
Date received:
Office code:

Request filed late:

1. Applicant’s Name:

2. Social Security Number:
3. Medicare Number (the number is printed on your Medicare card):
4. Spouse’s Name (if spouse lives at same address as you):
5. Spouse’s Social Security Number (if spouse lives at same address as you):

6. Spouse's Medicare Number (if spouse lives at same address as you):

7. Please explain why you disagree with our decision:

8. Do you have additional information to support your appeal?
YES (Send the additional information with this form to the address shown on the bottom
of page 2).
NO
9. Do you want a hearing? If you have a hearing, it will be by telephone.
YES (You will receive a notice with the date and time of the hearing. Please complete
questions 10 through 13).
NO (You will receive a decision based on the information available and any additional
information you provide).
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Form SSA-1021 (10/2024)

10. To give you time to prepare for the hearing, we allow at least 20 days between the date of your
request and the date we schedule the hearing. Do you want a hearing sooner if scheduling permits?
YES
NO
11. Do you need an interpreter?
YES (Specify language):
NO
12. Are you hearing impaired?
YES
NO
13. Will you have other people at the hearing?
YES
NO
If YES, will you and the other people need to talk to us from more than one telephone number?
YES

We call this a conference call. When we send you the notice with your hearing date
and time, we will also give you a telephone number and additional instructions for
this conference call.

NO

Please return your completed appeal form, including the signature page, and any additional
information to:
Social Security Administration
Wilkes-Barre Direct Operations Center
P.O. Box 1030
Wilkes-Barre, PA 18767-1030
Form SSA-1021 (10-2024)

Page 2

Signatures
I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true to the best of my knowledge. I understand that making
a false statement is a crime punishable under Federal law. By submitting this appeal, I am authorizing the
Social Security Administration to obtain and disclose information related to my income resources and
assets, foreign and domestic, consistent with applicable privacy laws. This information may include, but
is not limited to, information about my wages, account balances, investments, benefits, and pensions.
Please complete Section A. If you cannot sign, a representative may sign for you. If someone assisted you,
complete Section B as well.

SECTION A
Your Signature:

Phone Number:
(
) ______ - ________

Your Home Street Address:

Apt. #:

City:

State:

Your Mailing Street Address (if different from home address):
City:

ZIP Code:
Apt. #:

State:

ZIP Code:

If you recently changed your address, put an X here:
If you would prefer that we contact someone else if we have additional questions, please provide the
person’s name and a daytime phone number.
Print First Name:

Print Last Name:

Phone Number:
( _____ ) ______ - ________

SECTION B
If someone assisted you, place an X in the box that describes that person and provide the rest of the
information requested below.

Form SSA-1021 (10-2024)

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Family Member

Attorney

Advocate

Friend

Agency

Social Worker

Print First Name:

Print Last Name:

Address:
City:

Other
Specify:

Phone Number:
( _____ ) ______ - ________
Apt. #:
State:

ZIP Code:

See Revised

Privacy Act Statement
Privacy Act
Statement
Collection and Use of Personal Information

Section 1860 D-14 of the Social Security Act, as amended, allows us to collect this information. We will
use the information you provide to determine your eligibility for help paying your share of the cost of a
Medicare Prescription Drug Plan.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the requested
information could prevent an accurate and timely decision on your appeal. We rarely use the information
you supply for any purpose other than for making a determination about your continuing entitlement to
benefits. However, we may use the information for the administration of our programs including sharing
information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans’ Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity
and improvement of our programs (e.g., to the Bureau of the Census and private concerns under
contract to Social Security).
A complete list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notice 60-0321, entitled Medicare Database. Additional information about
this and other system of records notices and our programs are available from our Internet website at
www.ssa.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching programs.
Matching programs compare our records with records kept by other Federal, State, or local government
agencies. We use the information from these programs to establish or verify a person’s eligibility for
federally funded or administered benefit programs and for repayment of incorrect payments or delinquent
debts under these programs.
Form SSA-1021 (10-2024)

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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
control number. We estimate that it will take about 10 minutes to read the instructions, gather
the facts, and answer the questions. You may send comments on our time estimate above to:
Social Security Administration, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.

Form SSA-1021 (10-2024)

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