SSA-8510 – Medicare Subsidy Quality Review (paper version)

Authorization for the Social Security Administration to Obtain Personal Information

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0801 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-8510 SSA-8510 – Medicare Subsidy Quality Review (paper version) Form
SSA-8510 Authorization for the Social Security Administration to SSA-8510.pdf Form

Information Collection (IC) Details

IC Title:	SSA-8510 – Medicare Subsidy Quality Review (paper version)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1926 20 CFR 416.203 20 CFR 404.704 20 CFR 404.820 - 404.823 20 CFR 418.3001

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-8510	Authorization for the Social Security Administration to Obtain Personal Information	SSA-8510.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	292	292
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.