Form SSA-9312 Notice of Appointment -Denial- Please Call Reviewer

Social Security Administration
Office of Quality Review
(Address of Office)
Date:
Beneficiary:
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, I would like you to telephone me at my office 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 YOU CALL
I will identify myself by name as shown at the bottom of this letter. I will ask you some
questions about the information given on (fill-in 4) application for help with Medicare
prescription drug plan costs.
HOW YOU CAN GET READY FOR YOUR CALL
I have enclosed a page that shows the kinds of information you should have ready. I
have checked the things I would like to talk about. If you do not have all of the
information that I am requesting, I 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 you call.
PLEASE RETURN THE ENCLOSED FORM
I have enclosed an acknowledgement form for you to complete, sign and mail
back to me in the envelope I have provided. You do not need to put a stamp on
the envelope. This form is to let me know you received the letter and whether or
not you will be able to call me.
Notice of Appointment-Denial-Please Call Reviewer
SSA-9312 (Rev 11-2014)

If you have any questions, please call me at my office between 8:00 a.m. and 4:00 p.m.,
Monday through Friday. My toll-free number is 1-800- ______. Thank you for your
help.
Sincerely,

Social Insurance Specialist
Enclosures

Notice of Appointment-Denial-Please Call Reviewer
SSA-9312 (Rev 11-2014)

PRIVACY ACT AND PAPER REDUCTION ACT NOTICE
See Revised Privacy Act
and PRA Statement

COLLECTION AND USE OF PERSONAL INFORMATION

Section 1860 D-14 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 this information with others, called routine uses, is
available in our Privacy Act Systems 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.
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 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, 6401 Security Blvd., Baltimore, MD 21235-6401.

Notice of Appointment-Denial-Please Call Reviewer
SSA-9312 (Rev 11-2014)

SSA will insert the following revised Privacy Act Statement into the form as soon as
possible:
Privacy Act Statement
Collection and Use of Personal Information

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.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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.

ACKNOWLEDGEMENT FORM
(RETURN THIS SHEET IMMEDIATELY)
_________________________________________________________________________________
Beneficiary’s Name

1. Will you be available at the time requested?

_______________________
Beneficiary’s SSN

□ 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.

_________________________________________________________________________________

□ Yes □ No

4. Is your address shown correctly on this letter?
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-Please Call Reviewer
SSA-9312 (Rev 11-2014)