Form SSA-4-BK Application for Child's Insurance Benefits

See Revised Privacy Act
Statement Attached

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 202, 205, 223, 1818, 1836, and 1840 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 any claim
filed, or could result in the loss of benefits.
We will use the information you provide to determine eligibility for monthly benefits or
insurance coverage and to authorize payments to the children of retired, disabled, or deceased
workers. We may also share your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies (or agents on their behalf) for administering cash or
non-cash income maintenance or health maintenance programs (including programs
under the Act).
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA
in the efficient administration of its programs. We contemplate disclosing information
under this routine use only in situations in which SSA may enter a contractual or similar
agreement with a third party to assist in accomplishing an agency function relating to this
system of records.
3. To the Centers for Medicare & Medicaid Services, for the purpose of administering
Medicare Part A, Part B, Medicare Advantage Part C, and Medicare Part D.
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) 60-0089, entitled Claims Folder System, and 60-0321, entitled Medicare Database
(MDB) File. Additional information and a full listing of all our SORNs are available on our
website at www.socialsecurity.gov/foia/bluebook.