Form SSA-9308 Request for Release of Information

Social Security Administration
Office of Quality Performance
(Address of Office)

Date:
Beneficiary:
SSN:

(Address)

The Social Security Administration is conducting a quality review on this account.
The following information is needed for our review for the above named individual.
We have included a signed authorization for release of the information and a selfaddressed stamped envelope for your convenience.

(fill-in)

We appreciate your assistance with our review. If you have any questions, you
may phone me at my office between 8:00 a.m. and 4:00 p.m., Monday through
Friday. My toll-free telephone number is 1-800- _____.
Sincerely,

Social Insurance Specialist

Enclosures: Postage-paid envelope
Signed Authorization for Release of Information

Request for Information
SSA-9308 (4-2007)

Please see revised PRA Statement below.

PAPER REDUCTION ACT NOTICE
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.

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.

Request for Information
SSA-9308 (4-2007)

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
reprinting:
Privacy Act Statement
Request for Information

Section 1860 D-14 of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide to conduct a quality review of your
account for the beneficiary named on your application.
The information you furnish on this form is voluntary. However, failure to provide all or part of
the information could prevent us from making an accurate and timely decision regarding your
eligibility and appeal rights.
We rarely use the information you 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 an agency to assist Social Security in establishing rights to
Medicare 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 the Department of Veterans’
Affairs);
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, or investigative activities necessary to assure the
integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for Federally-funded or administered benefit programs and for repayment of
payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in System of Records Notice
entitled, Medicare Database (MDB) File, 60-0321. This notice, additional information regarding
this form, and information regarding our programs and systems, are available on-line at
http://www.socialsecurity.gov or at your local Social Security office.