Form SSA-9311 Notice of Appointment -Denial- Reviewer Will Call

Social Security Administration
Office of Quality Performance
(Address of Office)
Date:
Beneficiary Name:
SSN:
(Address)

The Social Security Administration is contacting a few people who have applied for
extra help with Medicare prescription drug plan costs. We are doing a quality review to
make sure we made the correct decision on these applications. We picked (fill-in 1)
name by chance, NOT for any other reason. To make sure we made the correct
decision on (fill-in 2) application, I would like to telephone you on (fill-in 3). For
general information about Social Security or to verify that this is an official
communication, you can call our national toll-free number at 1-800-772-1213.
IMPORTANT INFORMATION
You do not have to give us the requested information. However, if you do not provide
the information, we will not be able to evaluate if the denial of your request for extra
help with Medicare prescription drug plan costs was correct. The Social Security law
that allows us to ask you questions is explained in the enclosed page, Privacy Act and
the Paper Reduction Act Notice.
WHAT WILL HAPPEN WHEN I CALL
I will identify myself by name as shown at the bottom of this letter. I will ask you some
questions about the information on (fill-in 4) application for help with Medicare
prescription drug plan costs.
HOW YOU CAN GET READY FOR YOUR CALL
I have enclosed a page that shows the kinds of information you should have ready. I
have checked the things I would like to talk about. If you do not have all of the
information that I am requesting, I can help you get the information you do not have. If
you would like to have a friend or relative help you, please tell that person to be there
when I call.
PLEASE RETURN THE ENCLOSED FORM
I have enclosed an acknowledgement form for you to complete, sign and mail
back to me in the envelope I have provided. You do not need to put a stamp on
the envelope. This form is to let me know you received this letter and whether or
not you will be available when I plan to call you.

Notice of Appointment – Denial –Reviewer Will Call
SSA-9311(4-2007)

If you have any questions, please call me at my office between 8:00 a.m. and 4:00
p.m., Monday through Friday. My toll-free number is 1-800- ______. Thank you for
your help.
Sincerely,

Social Insurance Specialist

Enclosures

Notice of Appointment-Denial-Reviewer Will Call
SSA-9311 (4-2007)

PRIVACY ACT AND PAPER REDUCTION ACT NOTICE
COLLECTION AND USE OF INFORMATION

See revised
Privacy Act
The Social Security Administration is authorized by section 1860 D-14 of the Social
Statement below.
Security Act to collect the information requested in this interview. The information you
give us, along with the information we get from other people we interview, helps us to
know where there are problems in the programs for which the Social Security
Administration is responsible. It also helps us to resolve these problems and
recommend changes in the law.
You do not have to give us the requested information. However, if you do not provide
the information, we will not be able to evaluate if the denial of your request for extra
help with Medicare prescription drug plan costs was correct.

HOW THE INFORMATION IS USED
The information you provide may be disclosed to another Federal, State or local
government agency for determining eligibility for a government benefit or program, to a
Congressional office requesting information on your behalf, to an independent party for
the performance of research and statistical activities, to the Department of Justice for
use in representing the Federal Government, or if a Federal law requires that we give
out this information.
We may also use this information when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government
agencies. Many agencies may use matching programs to find or prove that a person
qualifies for benefits paid by the Federal Government. This law allows us to do this
even if you do not agree to it.
Explanations about these and other reasons why information you provide may be used or
given out are available in Social Security offices. If you want to learn more about this,
contact any Social Security office.
Paperwork Reduction Act Statement – This information collection meets the requirements
of 44 U.S.C section 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 15 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments on our time
estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-0001.

Please see revised PRA statement below.

Notice of Appointment – Denial –Reviewer Will Call
SSA-9311(4-2007)

FORM APPROVED
OMB No. 0960-0707

ACKNOWLEDGEMENT FORM
(RETURN THIS SHEET IMMEDIATELY)
_________________________________________________________________________________
Beneficiary’s Name

1. Will you be available at the time requested?

□ Yes

_______________________
Beneficiary’s SSN

□ No

2. What telephone number can we use to reach you, including area code? (

)___________________

3. If you will not be available at the time requested, we can reschedule your appointment. If you would
like to reschedule, please let us know when you will be available at that number.
___________________________________________________________________
4. Is your address shown correctly on this letter? □ Yes □ No
If “NO”, please show the appropriate address below:
_________________________________________________________________________________
__________________________________________________________________________________
5. If you need assistance with the telephone interview due to a hearing impairment, please
check/complete the appropriate box(es) shown below:
□ I am deaf or hard of hearing. I will have a person to assist me with this telephone interview.
His/her name is _____________________. He/she is my __________________ (indicate
your relationship).
□ I am deaf or hard of hearing. SSA may call me with the assistance of a Telephone State
Relay System operator.
6. If you need assistance with the telephone interview due to language problems, please
check and complete the appropriate box(es) shown below:

□ I need a language interpreter. I speak__________________(indicate language).
□ I will provide a qualified language interpreter for this telephone interview. His/her name is
_____________________. He/she is my __________________ (indicate your relationship).
(Your interpreter should be 18 years of age or older).
□ I want SSA to provide a qualified language interpreter for this phone interview at no cost to
me.
Sign
here
_________________
►
___________________________________________________________________
_
Date
(SIGNATURE of Beneficiary or Payee if applicable)
QRA_____________________

Notice of Appointment – Denial –Reviewer Will Call
SSA-9311(4-2007)

FORM APPROVED
OMB No. 0960-0707

SSA will insert the following revised PRA Statement into the form at its next
scheduled reprinting:
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
(OMB) control number. The OMB control number for this collection is 0960-0707. We estimate
that it will take 15 minutes to read the instructions, gather the facts, and answer the questions.
Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.

__

Notice of Appointment-Denial-Reviewer Will Call
SSA-9311 (4-2007)

Privacy Act Statement
Request for Notice of Appointment – Denial

Section 1860 D-14 of the Social Security Act, as amended, authorizes us to collect the
information contained on this form. We will use the information to conduct a quality review of
applications and determine if we made the correct decision during the review process for those
applicants who requested additional assistance with the costs of the Medicare prescription drug
plan. Your responses are voluntary. However, failure to provide all or part of the requested
information may affect our ability to evaluate our decision for additional assistance with the
Medicare prescription drug plan.
We rarely use the information provided on this form for any other purpose other than the reasons
explained above. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include, but are not limited to the following:
1. To enable a third party or agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage.
2. To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office and Department of Veterans’
Affiars);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and
4. To facilitate statistical research, audit and investigative activities necessary to ensure the
integrity and improvement of Social Security programs.
We may also use the information you provided in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, and local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for Federally-funded and administered benefit programs.
A complete list of routine uses for this information is available in Systems of Records Notice,
entitled, Medicare Database (MDB) File, 60-0321. The notice, additional information regarding
this form, and information regarding our program and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security office.