Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy)

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) established the Medicare Part D program for voluntary prescription drug coverage of premium, deductible, and copayment costs for individuals with limited income and resources. The MMA mandates that the Government provide subsidies for those individuals who qualify for the program, and who meet eligibility criteria for help with premium, deductible, or co-payment costs. SSA uses the SSA–4640, Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare), to determine if subsidy applicants or recipients qualify, or continue to qualify, for the subsidy. SSA uses Form SSA–4640 to: (1) obtain the individual’s consent to verify balances of financial institution (FI) accounts; and (2) obtain verification of such balances from the FI. Respondents are Medicare Part D program subsidy applicants or claimants, and their financial institutions.

The latest form for Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy) expires 2029-08-31 and is listed under ICR 202606-0960-005.

View the official OMB control history on Reginfo.gov.

Medicare Part D Subsidy Applicants or Claimants

Federal Enterprise Architecture: Income Security - General Retirement and Disability

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