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

IC 9749 under ICR 202312-0960-004 · OMB 0960-0695.

Documents and Forms
Document Name
Document Type
Instruction
Other-Sample Denial Letter
Other-Privacy Act Statement (revised
Form
IC Document
IC Document
Information Collection (IC) Details

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Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version
 
No Modified
 
Voluntary
 
20 CFR 418.3101

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction SSA-1021 INST (Revised).pdf www.ssa.gov Yes No Printable Only
Form SSA-1021 Appeal of Determination for Help with Medicare Prescription Drug Plan Costs SSA-1021 (Revised).pdf www.ssa.gov Yes No Fillable Printable
Other-Sample Denial Letter sample denial notice.pdf No   Paper Only
Other-Privacy Act Statement (revised) SSA-1021 PA Statement (Revised).pdf No   Paper Only

Income Security General Retirement and Disability

 

1,859 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,859 0 0 -1,013 0 2,872
Annual IC Time Burden (Hours) 620 0 0 141 0 479
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Current SSA-1021 ssa-1021(Current).pdf 12/28/2023
SSA-1021- INST Instructions ssa-1021-inst (Current).pdf 12/28/2023
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.