Form SSA-9311 Notice of Appointment -Denial- Reviewer Will Call

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 have applied for
extra help with Medicare prescription drug plan costs. We are doing a quality review to
make sure we made the correct decision on these applications. 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) application, we would like to telephone you 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. However, if you do not provide
the information, we will not be able to evaluate if the denial of your request for extra help
with Medicare prescription drug plan costs was correct. 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.
WHAT WILL HAPPEN WHEN WE CALL
We will identify ourselves by name as shown at the bottom of this letter. We will ask
you some questions about the information on (fill-in 4) application for help with
Medicare prescription drug plan costs.
HOW YOU CAN GET READY FOR YOUR CALL
We have enclosed a page that shows the kinds of information you should have ready.
We have checked the things we would like to talk about. If you do not have all of the
information that we are requesting, we 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 we call.
PLEASE RETURN THE ENCLOSED FORM
We have enclosed an acknowledgment form for you to complete, sign and mail
back to us in the envelope we have provided. You do not need to put a stamp on
the envelope. This form is to let us know you received this letter and whether or
not you will be available when we plan to call you.

If you have any questions, please call us at our office between 8:00 a.m. and 4:00 p.m.,
Monday through Friday. Our toll-free number is 1-800. Thank you for your
help.
Notice of Appointment – Denial –Reviewer Will Call
SSA-9311(Rev 11-2014)

Sincerely,
Social Insurance Specialist

Enclosures

Notice of Appointment-Denial-Reviewer Will Call
SSA-9311 (Rev 11-2014)

PRIVACY ACT AND PAPER REDUCTION ACT NOTICE
Privacy Act Statement
Collection and Use of Personal Information

See Revised
Privacy Act
Statement
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 document your availability for an interview and to make a
determination of 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.
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.

Notice of Appointment – Denial –Reviewer Will Call
SSA-9311(Rev 11-2014)

Privacy Act Statement
Collection and Use of Personal Information
Section 1860D-14(a) 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 SSA’s inability to schedule an interview.
We will use the information to document your availability for an interview. We may also share
your information for the following purposes, called routine uses:
1. To the Centers for Medicare & Medicaid 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 (MDB File), as published in the Federal
Register (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.

FORM APPROVED
OMB No. 0960-0707

ACKNOWLEDGMENT 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 – Denial –Reviewer Will Call
SSA-9311(Rev 11-2014)