Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version

Appeal of Determination for Help with Medicare Prescription Drug Plan Costs

OMB: 0960-0695

IC ID: 9749

Documents and Forms

Document Name Document Type
SSA-1021 INST (Revised).pdf www.ssa.gov Instruction
SSA-1021 Appeal of Determination for Help with Medicare Prescription Drug Plan Costs SSA-1021 (Revised).pdf www.ssa.gov Form
sample denial notice.pdf Other-Sample Denial Letter
SSA-1021 PA Statement (Revised).pdf Other-Privacy Act Statement (revised)
ssa-1021(Current).pdf Current SSA-1021 IC Document
ssa-1021-inst (Current).pdf SSA-1021- INST Instructions IC Document