Revisions to the Collection Instrument
We are revising some of the language in the SSA-1021 form and instruction sheet to improve clarity. We will continue to use the old forms until stock runs out.
Change 1: We are changing the wording in question #6 on page 1 of the form.
Current language: Spouse’s Medicare Number (if different from Social Security number and spouse lives at same address as you):
Revised language: Spouse’s Medicare Number (if different from spouse’s Social Security number and spouse lives at same address as you):
Justification 1: We made this change to improve clarity
Change 2: We are changing the wording for the “NO” answer for question #9 on page 1 of the form.
Current language: NO You will receive a decision based on the information available and any additional information provided.
Revised language: NO You will receive a decision based on the information available and any additional information you provide.
Justification 2: We made this change to improve clarity.
Change 3: We are changing and moving the wording for the “YES” answer to part B of question #13 closer to the question on page 2 of the form.
Current language: If YES, we call this a conference call. When we send you the notice scheduling the hearing, we will give you a telephone number to use for this conference call and additional instructions for setting up this call.
Revised language: We call this a conference call. When we send you the notice scheduling the hearing, we will give you a telephone number to use for this conference call and instructions for setting up this call.
Justification 3: We made this change to improve clarity.
Change 4: We are changing the last sentence in the “Signatures” section on page 3 of the form.
Current language: If you are helping someone to complete this form, complete Section B as well.
Revised language: If someone assisted you, complete Section B as well.
Justification 4: We made this change to improve clarity and to align this form with the Application for Extra Help with Medicare Prescription Drug Plan Costs.
Change 5: We are changing the language in “Section B” on page 3 of the form.
Current language: If you are assisting someone else, place an X in the box that describes who you are and provide your daytime phone number and address.
Revised language: If someone assisted you place an X in the box that describes that person and provide the rest of the information requested below.
Justification 5: We made this change to improve clarity and to align this form with the Application for Extra Help with Medicare Prescription Drug Plan Costs.
Change 6: We are changing the wording in the section entitled, “WHEN TO USE THIS FORM” on the instruction sheet.
Current language: Use Form SSA-1021 to appeal SSA’s determinations regarding eligibility or continuing eligibility for a Medicare Part D subsidy.
Revised language: Use Form SSA-1021 to appeal Social Security’s determination regarding eligibility or continuing eligibility for Extra Help with your Medicare prescription drug plan costs.
Justification 6: We made this change to improve clarity.
Change 7: We are changing the wording for question #1 on the instruction sheet.
Current language: Name of the individual who is requesting the appeal.
Revised language: Print name as it appears on your Social Security card.
Justification 7: We made this change to improve clarity.
Change 8: We are changing the wording for question #2 on the instruction sheet.
Current language: Social Security number of the individual for whom the appeal is being filed.
Revised language: Print Social Security number as it appears on your Social Security card.
Justification 8: We made this change to improve clarity.
Change 9: We are changing the wording for question #3 on the instruction sheet.
Current language: Complete only if Medicare number differs from your Social Security number.
Revised language: Complete only if your Medicare number is different from your Social Security number.
Justification 9: We made this change to improve clarity
Change 10: We are changing the wording for question #4 on the instruction sheet.
Current language: Complete only if spouse lives at the same address.
Revised language: Print name as it appears on your spouse’s Social Security card. Complete only if your spouse lives at the same address.
Justification 10: We made this change to improve clarity.
Change 11: We are changing the wording for question #5 on the instruction sheet.
Current language: Complete only if spouse lives at the same address.
Revised language: Print Social Security number as it appears on your spouse’s Social Security card. Complete only if your spouse lives at the same address.
Justification 11: We made this change to improve clarity.
Change 12: We are changing the wording for question #6 on the instruction sheet.
Current language: Complete only if spouse lives at the same address and Medicare number differs from spouse’s Social Security number.
Revised language: Complete only if your spouse lives at the same address and his or her Medicare number is different from his or her Social Security number.
Justification 12: We made this change to improve clarity.
Revised language: Briefly state the determination that you disagree with and why you disagree with that determination. You can add to this statement by attaching additional pages.
Justification 13: We made this change to improve clarity.
Change 14: We are changing the wording for question #9 on the instruction sheet.
Current language: Check YES if you want a hearing by telephone. Check NO if you want a case review which means we will make a decision based on the information we have available and any additional information provided.
Revised language: Check YES if you want a hearing by telephone. Check NO if you do not want a hearing by telephone. If you do not want a hearing, we will make a decision based on the information we have available and any additional information you provide. We call this a case review.
Justification 14: We made changes to improve clarity.
Change 15: We are changing the wording for question #13 on the instruction sheet.
Current language: Check YES if you will have individuals other than yourself on the telephone conversation. Check YES again if you will have individuals calling in from a telephone number different from yours. Otherwise, check NO.
Revised language: Check YES if you will have people other than yourself on the telephone conversation. Check NO if you will not have any other people at the hearing by telephone. If YES, will you and the other people need to talk to us from more than one telephone number? Check YES if you will have people calling in from a telephone number different from yours. Otherwise, check NO.
Justification 15: We made changes to improve clarity.
Other Minor Revisions to the Collection Instrument
SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the form.
| File Type | application/msword |
| File Title | Title of Information Collection and Form Number(s) |
| Author | Naomi |
| Last Modified By | 889123 |
| File Modified | 2013-12-17 |
| File Created | 2013-12-17 |