SSA- 1026-REDE SSA Review of Your Eligibility for Extra Help

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-14 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 affect your eligibility for the Medicare Prescription Drug Plan (Part D) subsidy.
We will use the information to review and re-determine your eligibility for the Medicare Part D
subsidy. 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 pursuing
Medicare Part D and Part D subsidy entitlement or appeal rights; and
2. To the Centers for 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. Additional information and a full listing of
all our SORNs are available on our website at www.ssa.gov/privacy/sorn.html.