Third Party Liability Information Statement

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

Sections 205 and 1631 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent a timely and accurate decision on Medicaid eligibility.

We will use the information you provide to identify third party insurers liable for medical care or services for Medicaid beneficiaries. We may also share your information for the following purposes, called routine uses:

• To Federal, State, or local agencies (or agents on their behalf) for administering cash or non-cash income or health maintenance programs (including programs under the Act); and

• To State audit agencies for auditing State supplementation payments and Medicaid eligibility consideration.

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 Notices (SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784 and 60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits, as published in the FR on January 11, 2006, at 71 FR 1830. Additional information and a full listing of all our SORNs are available on our website at https://www.ssa.gov/privacy.

1/21/2021 5:16 AM