Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - MAPS Intranet Version

SSA will insert the following revised Privacy Act Statement into the form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 1631(c)(1)(A) and 1860 D-14 of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent a timely and accurate decision on your appeal.
We will use the information to determine your eligibility for assistance paying towards a
Medicare Prescription Drug Plan. We may also share your information for the following
purposes, called routine uses:
1. To applicants, claimants, prospective applicants or claimants (other than the data subjects
and their authorized representatives) to the extent necessary for the purpose of pursuing
Medicare Part D and Part D subsidy entitlement or appeal rights; and
2. To the Centers of Medicare and Medicaid Services (CMS), for the purpose of
administering Medicare Part D enrollment and premium collection and Medicare
Advantage Part C premium collections, as well as Medicare Part B income-related
monthly adjustment amounts.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0321, entitled Medicare Database File. Additional information and a full listing of
all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.