OMB control number

Appeal of Determination for Help with Medicare Prescription Drug Plan Costs

OMB 0960-0695 · SSA.

OMB 0960-0695

SSA uses Form SSA-1021, Appeal of Determination for Help With Medicare Prescription Drug Plan Costs, to obtain information from individuals who appeal SSA’s decisions regarding eligibility or continuing eligibility for a Medicare Part D subsidy. The respondents are Medicare beneficiaries, or proper applicants acting on behalf of a Medicare beneficiary, who do not agree with the outcome of an SSA subsidy eligibility determination, and are filing an appeal.

The latest form for Appeal of Determination for Help with Medicare Prescription Drug Plan Costs expires 2027-11-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Addendum - 0695 (Final).docx Supplementary Document
Supporting Statement - 0695 (Final).docx Supporting Statement A
Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version Instruction
Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - MAPS Intranet Version Other-Intranet Screens

All Historical Document Collections

202312-0960-004	Revision of a currently approved collection	2023-12-29
202008-0960-004	Revision of a currently approved collection	2020-10-06
201901-0960-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2019-02-01
201807-0960-019 Approved without change	No material or nonsubstantive change to a currently approved collection	2018-07-31
201703-0960-013 Approved without change	Revision of a currently approved collection	2017-06-13
201312-0960-002 Approved without change	Revision of a currently approved collection	2014-04-03
201007-0960-004 Approved without change	Revision of a currently approved collection	2010-12-10
200908-0960-012 Approved without change	No material or nonsubstantive change to a currently approved collection	2009-08-25
200712-0960-002 Approved without change	Extension without change of a currently approved collection	2007-12-12
200411-0960-004 Approved with change	New collection (Request for a new OMB Control Number)	2004-11-17

OMB Details

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

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form		www.ssa.gov	Instruction
Form SSA-1021	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs	www.ssa.gov	Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.