Ssa-9303

Medicare Subsidy Quality Review

Documents and Forms

Document Name Document Type
SSA-9304 (current version).pdf Instruction
SSA-9303 Notice of Appointment - Please Call Reviewer (Revised) SSA-9303 (revised version).pdf Form and Instruction
SSA-9303 (current version).pdf Current SSA-9303 IC Document

Information Collection (IC) Details

IC Title:	SSA-9303	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 418.(b)(5)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			SSA-9304 (current version).pdf		No		Paper Only
Form and Instruction	SSA-9303	Notice of Appointment - Please Call Reviewer (Revised)	SSA-9303 (revised version).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 350	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	350	350
Annual IC Time Burden (Hours)	88	88
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-9303	SSA-9303 (current version).pdf	07/14/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.