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Form Ssa-1021-Inst - Instructions For Completing The Appeal Of Determination For Extra Help With Medicare Prescription Drug Plan Costs

Instructions for Completing the Appeal of Determination for

Extra Help with Medicare Prescription Drug Plan Costs

WHEN TO USE THIS FORM: Use Form SSA-1021 to appeal Social Security's

determination regarding eligibility or continuing eligibility for Extra Help with your

Medicare prescription drug plan costs.

1. APPLICANT'S NAME:

Print name as it appears on your Social Security card.

2. SOCIAL SECURITY NUMBER:

Print Social Security number as it appears on your Social Security card.

3. MEDICARE NUMBER:

Complete only if your Medicare number is different from your Social Security number.

4. SPOUSE'S NAME:

Print name as it appears on your spouse's Social Security card. Complete only if your

spouse lives at the same address

5. SPOUSE'S SOCIAL SECURITY NUMBER:

Print Social Security number as it appears on your spouse’s Social Security card. Complete

only if your spouse lives at the same address.

6. SPOUSE'S MEDICARE NUMBER:

Complete only if your spouse lives at the same address and his or her Medicare number is

different from his or her Social Security number.

7. PLEASE EXPLAIN WHY YOU DISAGREE WITH OUR DECISION:

Briefly state the determination that you disagree with and why you disagree with that

determination. You can add to this statement by attaching additional pages.

8. DO YOU HAVE ADDITIONAL INFORMATION TO SUPPORT YOUR APPEAL:

If there is more information you want us to see, you can mail it with this form to:

Social Security Administration

Wilkes-Barre Data Operations Center

P.O. Box 1030

Wilkes-Barre, PA 18767-1030

9. DO YOU WANT A HEARING?

Check YES if you want a hearing by telephone. Check NO if you do not want a hearing by

telephone. If you do not want a hearing, we will make a decision based on the information

we have available and any additional information you provide. We call this a case review.

10. DO YOU WANT A HEARING SOONER IF SCHEDULING PERMITS?

We must allow at least 20 days from the date we receive your appeal request and the date

we schedule the hearing to give you time to prepare. If you want a hearing sooner, check

YES. Check NO if you want us to schedule the hearing at least 20 days from the date we

receive your appeal request.

SSA-1021-INST

Page 1

Form

(07-2014)

Form Ssa-1021-Inst - Instructions For Completing The Appeal Of Determination For Extra Help With Medicare Prescription Drug Plan Costs