Current SSA-9310

Social Security Administration
Office of Quality Performance
(Address of Office)
Date:
Beneficiary Name:
SSN:

(Address)

On (fill-in 1), I spoke with you regarding the review of (fill-in 2).In order to proceed with
the review, the following is needed:

(fill-in 3)

Please send the requested documents in the enclosed self-addressed, postage-paid
envelope. We will return your documents immediately.
If you have questions about this request, contact me at 1-800-______ between 8:00 a.m.
and 4:00 p.m., Monday through Friday.
Thank you for your cooperation.

Sincerely,

Social Insurance Specialist

Enclosure(s)

Request for Documents
SSA-9310 (4-2007)

Please see revised PRA Statement below.

PAPER REDUCTION ACT NOTICE
Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C
section 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 15 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-0001.

SSA will insert the following revised PRA Statement into the form at its next
scheduled reprinting:
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 5 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 Documents
SSA-9310 (4-2007)

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
reprinting:
Privacy Act Statement
Request for Documents

Section 1860 D-14 of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide, along with the information we receive
from other people we interview, to conduct a quality review of applications and determine if we
made the correct decision during the review process for those applicants who requested extra
help with Medicare prescription drug costs.
The information you furnish on this form is voluntary. However, failure to provide all or part of
the requested documents required affects our ability to proceed with the review of your request
for extra help with Medicare prescription drug costs.
We rarely use the information you supply for any purpose other than for determining problems in
Social Security programs. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include, but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Medicare benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office and the Department of Veterans’
Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for Federally-funded or administered benefit programs and for repayment of
payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in System of Records Notice
entitled, Medicare Database (MDB) File, 60-0321. This notice, additional information regarding

this form, and information regarding our programs and systems, are available on-line at
http://www.socialsecurity.gov or at your local Social Security office.