Form SSA-9308 Request for Release of Information

Social Security Administration
Office of Quality Performance 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 me at my office between 8:00 a.m. and 4:00 p.m., Monday through
Friday. My 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 (2-2012)

PAPER REDUCTION ACT NOTICE
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 for 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 on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401.

Request for Information
SSA-9308 (2-2012)

Privacy Act Statement
Collection and Use of Personal Information

Section 1860 D-14 of the Social Security Act 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 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 your information with others, called routine uses, is
available in our Privacy Act System 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.