Form SSA-9314 Notice of Quality Review Acknowledgement Form for those

Social Security Administration
Office of Quality Review
(Address of Office)
Date:
Beneficiary Name:
SSN:
(Address)
The Social Security Administration is contacting a few people who had a recent
redetermination of their extra help with Medicare prescription drug plan costs. We are
doing a quality review to make sure we made the correct decision on these
redeterminations. We picked (fill-in 1) name by chance, NOT for any other reason. To
make sure we made the correct decision on (fill-in 2) redetermination, I would like you
to telephone me at my office on (fill-in 3). For general information about Social Security
or to verify that this is an official communication, you can call our national toll-free
number at 1-800-772-1213.
IMPORTANT INFORMATION
You do not have to give us the requested information. If you do provide the information
and your subsidy level is correct, we will not have to contact you to review your eligibility
for at least another year unless you report a subsequent change in your income,
resources, or household size. However, if the information is incorrect or you do not
provide the information, we may contact you to review your eligibility within the next few
months. Such review of your eligibility could result in your subsidy level increasing,
decreasing, or stopping. The Social Security law that allows us to ask you questions is
explained in the enclosed page, Privacy Act and the Paper Reduction Act Notice.
Your cooperation with this review will help us to ensure the process for helping
Medicare beneficiaries with their prescription drug costs is providing the correct help to
the correct people.
We would also like to remind you that if you (and your spouse if married and living
together) have a change in your income, resources, or household size, you should
report this information to Social Security.
WHAT WILL HAPPEN WHEN YOU CALL
I will identify myself by name as shown at the bottom of this letter. I will ask you some
questions about the information on (fill-in 4) recent redetermination of the extra help
with Medicare prescription drug plan costs.
Notice of Appointment-Redetermination–Please Call Reviewer
SSA-9314 (Rev 11-2014)

HOW YOU CAN GET READY FOR YOUR CALL
I have enclosed a page that shows the kinds of information you should have ready. I
have checked the things I would like to talk about. If you do not have all of the
information that I am requesting, I can help you get the information you do not have. If
you would like to have a friend or relative help you, please tell that person to be there
when you call.
PLEASE RETURN THE ENCLOSED FORM
I have enclosed an acknowledgement form for you to complete, sign and mail
back to me in the envelope I have provided. You do not need to put a stamp on
the envelope. This form is to let me know you received this letter and whether or
not you will be able to call me.
If you have any questions, please call me at my office between 8:00 a.m. and 4:00 p.m.,
Monday through Friday. My toll-free number is 1-800- ______. Thank you for your
help.
Sincerely,

Social Insurance Specialist
Enclosures

Notice of Appointment-Redetermination-Please Call Reviewer
SSA-9314 (Rev 11-2014)

PRIVACY ACT AND PAPER REDUCTION ACT NOTICE
See Revised Privacy
COLLECTION AND USE OF PERSONAL INFORMATION Act and PRA
Statement
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 your 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 the 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 your information with others, called routine uses, is
available in our Privacy Act Systems of Records Notice 60-0321, entitled Medicare Database.
Additional information regarding 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 (OMB) control number. The OMB
control number of 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.

Notice of Appointment-Redetermination–Please Call Reviewer
SSA-9314 (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 result in changes or termination of your Medicare Part D subsidy.
We will use the information to document your availability for an interview and to make a
determination of 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
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.

FORM APPROVED
OMB No. 0960-0707

ACKNOWLEDGEMENT FORM
(RETURN THIS SHEET IMMEDIATELY)
_________________________________________________________________________________

_______________________

Beneficiary’s Name

Beneficiary’s SSN

1. Will you be available at the time requested? □ Yes □ No
2. What telephone number can we use to reach you, including area code?
( )____________________
3. If you will not be available at the time requested, we can reschedule your appointment. If you would
like to reschedule, please let us know when you will be available at that number.
_______________________________________________________________________________
4. Is your address shown correctly on this letter? □ Yes □ No
If “NO,” please show the appropriate address below:
_______________________________________________________________________________
_______________________________________________________________________________
5. If you need assistance with the telephone interview due to a hearing impairment, please
check/complete the appropriate box(es) shown below:
□ I am deaf or hard of hearing. I will have a person to assist me with this telephone interview.
His/her name is _____________________. He/she is my __________________ (indicate
your relationship).
□ I am deaf or hard of hearing. SSA may call me with the assistance of a Telephone State
Relay System operator.
6. If you need assistance with the telephone interview due to language problems, please
check and complete the appropriate box(es) shown below:
□ I need a language interpreter. I speak__________________ (indicate language).
□ I will provide a qualified language interpreter for this telephone interview. His/her name is
_____________________. He/she is my __________________ (indicate your relationship).
(Your interpreter should be 18 years of age or older).
□ I want SSA to provide a qualified language interpreter for this phone interview at no cost to
me.
Sign
here

►

____________________________________________________________________

______________________

(SIGNATURE of Beneficiary or Payee if applicable)

Date
QRA_______________________

Notice of Appointment-Redetermination–Please Call Reviewer
SSA-9314 (Rev 11-2014)