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 us at our office between 8:00 a.m. and 4:00 p.m., Monday through
Friday. Our 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
Privacy Act Statement
See Revised
Collection and Use of Personal Information
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 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.
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.

Request for Information
SSA-9308 (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 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, prospective applicants or claimants (other than the data subjects
and their authorized representatives) 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 (MDF), 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.