Form SSA-9310 Request for Documents

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

(Address)

On (fill-in 1), I spoke with you regarding the review of (fill-in 2). In order to proceed with
the review, the following is needed:

(fill-in 3)

Please send the requested documents in the enclosed self-addressed, postage-paid
envelope. We will return your documents immediately.
If you have questions about this request, contact me at 1-800-______ between 8:00 a.m.
and 4:00 p.m., Monday through Friday.
Thank you for your cooperation.

Sincerely,

Social Insurance Specialist

Enclosure(s)

Request for Documents
SSA-9310 (Rev 11-2014)

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

See Revised
Actallows us to collect this information.
Section 1860 D-14 of the Social Security
Act, asPrivacy
amended,
We will use the information you provide
to determine
your continued eligibility for help paying
and PRA
Statement
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 §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 (OMB) control number. The OMB control number for this collection
is 0960-0707. We estimate that it will take 5 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 Documents
SSA-9310 (Rev 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 prevent us from evaluating the denial of your Medicare Part D subsidy request.
We will use the information to make a determination of eligibility or continued eligibility for
benefits. We may also share your information for the following purposes, called routine uses:
1. To the Centers for Medicare & Medicare Services, 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; and
2. To Federal and State agencies administering Medicare Part D and Part D subsidy under
the Medicare Prescription Drug Improvement and Modernization Act of 2003.
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 5
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.