Personal Interview (SSA Field Office)

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

Sections 1839(i) and 1860D-13(a) 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 an accurate and timely decision on your claim.
We will use the information to determine if you qualify for a reduction in your monthly
Medicare Part B and/or prescription drug coverage income-related monthly adjustment amount.
We may also share your information for the following purposes, called routine uses:
1. To applicants, claimants, prospective applicants or claimants (other than the data subjects
and their authorized representatives) to the extent necessary for the purpose of
administering Medicare Part A, Part B, Medicare Advantage Part C, and Medicare Part
D, including, but not limited to pursuing Medicare Part B, Part C, and Part D premium
collection; and
2. To the Centers for Medicare and Medicaid Services, for the purpose of administering
Medicare Part A, Part B, Medicare Advantage Part C, and Medicare Part D, including but
not limited to: Medicare Part C enrollment and premium collection processes; Part D
enrollment and premium collection processes; Medicare Part B premium reduction based
on participation in a Part C plan and Medicare Part B enrollment and income-related
monthly adjustment amount determinations, appeals of determinations, and premium
collection.
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.
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 45 minutes to read the instructions, gather
the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA’s website

at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.