Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version

Privacy Act Statement
Collection and Use of Personal Information
Section 1860 D-14 of the Social Security Act, as amended, allows us to collect your information
or the information you are submitting on behalf of another, which we will use to determine your
eligibility for help paying your share of the cost of a Medicare Prescription Drug Plan.
Providing the information is voluntary, but not providing all or part of the information may
prevent us from assisting you with the request. As law permits, we may use and share the
information you submit, including with other Federal, State, and local agencies, contractors, and
others as outlined in the routine uses within System of Records Notice (SORN) 60-0321,
available at www.ssa.gov/privacy. The information you submit may also be used in computer
matching programs to establish or verify eligibility for Federal benefit programs and to recoup
debts under these programs.