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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
OMB.report
SSA
OMB 0960-0695
ICR 202312-0960-004
IC 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
Information Collection (IC) Details
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