Form SSA-9308 Request for Release of Information

Social Security Administration
Office of Quality Review

(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 (11-2014)

PRIVACY ACT AND PAPER REDUCTION ACT NOTICE
See Revised Privacy Act
and PRA Statement

COLLECTION AND USE OF PERSONAL INFORMATION

Section 1860 D-14 of the Social Security Act, as amended, allows us to collect this
information. We will use the information you provide to determine your continued
eligibility for help paying your share of the cost of a Medicare Prescription Drug Plan.
Furnishing us this information is voluntary. However, failing to provide us with all or part
of the information could result in a change or termination of your subsidy.
We rarely use the information you supply for any purpose other than what we state
above, however, we may use the information for the administration of our programs
including sharing information:
1. To comply with Federal laws requiring the release of information from our
records (e.g., to the Government Accountability Office and Department of Veterans’
Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to
ensure the integrity and improvement of our programs (e.g., to the Bureau of the
Census and to private entities under contract with us).
A complete list of when we may share this information to others, called routine uses, is
available in our Privacy Act Systems of Records Notice 60-0321, entitled Medicare
Database. Additional information about this and other system of records notices and our
programs are available from our Internet website at www.socialsecurity.gov or at your
local Social Security office.
We may share the information you provide to other health agencies through computer
matching programs. Matching programs compare our records with records kept by other
Federal, State, or local government agencies. We use the information from these
programs to establish or verify a person’s eligibility for federally funded or administered
benefit programs and for repayment of incorrect payments or delinquent debts under
these programs.
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 control number. The OMB control number for this
collection is 0960-0707. 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, 6401 Security Blvd., Baltimore, MD 21235-6401.

Request for Information
SSA-9308 (11-2014)

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

Section 1860D-14A of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may result in changes or termination of the named beneficiary’s Medicare Part D
subsidy.
We will use the information to make a determination about the beneficiary’s continued eligibility
for benefits. We may also share your information for the following purposes, called routine
uses:
1. To applicants, claimants, or prospective applicants to the extent necessary for the purpose
of pursuing Medicare Part D and Part D subsidy entitlement or appeals rights; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration in the efficient administration of its programs.
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.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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. We estimate that it will take about
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.