Request for Reconsideration--Paper and MCS/SSI Claims System

SSA will insert the following revised Privacy Act and PRA Statements into the form as soon as
possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205, 702(a)(5), 809, 1631, 1633, and 1869(b) 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 us from re-evaluating the decision on
your claim.
We will use the information to determine your eligibility for benefits and administer our
programs. We may also share your information for the following purposes, called routine uses:
•

To third party contacts in situations where the party to be contacted has, or is expected to
have, information relating to the individual’s capability to manage his/her affairs or
his/her eligibility for or entitlement to benefits under the Social Security program; and

•

To the Center for Medicare & Medicaid Services (CMS), for the purpose of
administering Medicare Part A, Part B, Medicare Advantage Part C, and Medicare Part
D, including but not limited to: Medicare Part C enrollment and premium collection
processes; Part D enrollment and premium collection processes; Medicare Part B
premium reduction based on participation in a Part C plan; and Medicare Part B
enrollment and income-related monthly adjustment amount determinations, appeals of
determinations, and premium collections.

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 Notices
(SORN) 60-0089, entitled Claims Folder System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784 and 60-0321, entitled Medicare Database File, as published in the
FR on July 25, 2006, at 71 FR 42159. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy/.
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. We estimate that it will take about 8 minutes to read the instructions, gather
the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA’s website
at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your

telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-3250778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form,