SSA-1021 Appeal of Determination for Help with Medicare Prescript

Form Approved
OMB No. 0960-0695

Appeal of Determination for
Extra Help with Medicare
Prescription Drug Plan Costs

Privacy Act / Paperwork Reduction Notice
Sections 1631(c)(1)(A) and 1860 D-14 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 your appeal.
We will use the information to determine your eligibility for assistance paying towards a
Medicare Prescription Drug Plan. We may also share your information for the following
purposes, called routine uses:

FOR OFFICIAL USE ONLY
Date received:
Office code:

Request filed late:

1. Applicant’s Name:

2. Social Security Number:

 To applicants, claimants, prospective applicants or claimants (other than the data subjects

and their authorized representatives) to the extent necessary for the purpose of pursuing
Medicare Part D and Part D subsidy entitlement or appeal rights; and

 To the Centers of Medicare and Medicaid 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.

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, as published in the Federal Register (FR)
on July 25, 2006, at 71 FR 42159. Additional information and a full listing of all our SORNs
are available on our website at www.ssa.gov/privacy.
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 10 minutes to read the instructions, gather
the facts, and answer the questions. You may send comments on our time estimate above to:
Social Security Administration, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.

3. Medicare Number (if different from Social Security number):

4. Spouse’s Name (if spouse lives at same address as you):

5. Spouse’s Social Security Number (if spouse lives at same address as you):

6. Spouse’s Medicare Number (if different from spouse’s Social Security number and spouse lives at
same address as you):

7. Please explain why you disagree with our decision:

8. Do you have additional information to support your appeal?
YES Send the additional information with this form to the address shown on the bottom
of page 2.
NO
9. Do you want a hearing? If you have a hearing, it will be by telephone.
YES You will receive a notice with the date and time of the hearing. Please complete
questions 10 through 13.
NO You will receive a decision based on the information available and any additional
information you provide.

Form

SSA-1021 (05-2018)

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Form

SSA-1021 (05-2018)

Page 1

Signatures

YES

I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true to the best of my knowledge. I understand that making
a false statement is a crime punishable under Federal law. By submitting this appeal, I am authorizing the
Social Security Administration to obtain and disclose information related to my income, resources and
assets, foreign and domestic, consistent with applicable privacy laws. This information may include, but is
not limited to, information about my wages, account balances, investments, benefits, and pensions.

NO

Please complete Section A. If you cannot sign, a representative may sign for you. If someone assisted you,
complete Section B as well.

10. To give you time to prepare for the hearing, we must allow at least 20 days between the date
of your request and the date we schedule the hearing. Do you want a hearing sooner if
scheduling permits?

11. Do you need an interpreter?
YES (Specify language): __________________________________________________

SECTION A

Your Signature:

Phone Number:

Your Home Street Address:

NO

Apt. #:

City:

12. Are you hearing impaired?

State:

YES

Your Mailing Street Address (if different from home address):

NO

City:

ZIP Code:
Apt. #:

State:

ZIP Code:

13. Will you have other people at the hearing?
YES

If you recently changed your address, put an

NO

If you would prefer that we contact someone else if we have additional questions, please provide the
person’s name and a daytime phone number.

If YES, will you and the other people need to talk to us from more than one telephone number?
YES We call this a conference call. When we send you the notice scheduling the hearing,
we will give you a telephone number to use for this conference call and additional
instructions for setting up this call.
NO

Please return your completed appeal form, including the signature page, and any additional
information to:
Social Security Administration
Wilkes-Barre Direct Operations Center
P.O. Box 1030
Wilkes-Barre, PA 18767-1030

Print First Name:

here:

Print Last Name:

SECTION B
If someone assisted you, place an
information requested below.

in the box that describes that person and provide the rest of the

Family Member

Attorney

Advocate

Friend

Agency

Social Worker

Print First Name:

Print Last Name:

SSA-1021 (05-2018)

Page 2

Other
Specify:________________
______________________
Phone Number:

Address:

Apt. #:

City:
Form

Phone Number:

Form

State:
SSA-1021 (05-2018)

Page 3

ZIP Code: