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  • Ssa 1021

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Form Approved OMB No. 0960-0695 Appeal of Determination for Extra Help with Medicare Prescription Drug Plan Costs 1. Applicant's Name: FOR OFFICIAL USE ONLY Date received: Office code: Request filed.

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If You Were Denied For Medical Reasons If you do not wish to appeal a medical decision online, you can use the Form SSA-561, Request for Reconsideration.

Form SSA-1021 (04-2021) Appeal of Determination for. Extra Help with Medicare. Prescription Drug Plan Costs.

Appeal process Set a date for a hearing by calling your local SSA office or the national hotline at 800-772-1213. You can also download an online form and mail it to request a hearing. Generally, SSA will suggest a date at least 20 days after your request, giving you time to prepare.

SSA and its affiliated State disability determination services use Form SSA-827, "Authorization to Disclose Information to the Social Security Administration (SSA)" to obtain medical and other information needed to determine whether or not a claimant is disabled.

To help Social Security determine if you are eligible for Extra Help, you will need to file an Application for Extra Help with Medicare Prescription Drug Plan Costs (Form SSA-1020).

You can request one online by using your my Social Security account, which will allow you to immediately view, print, and save a copy of the letter. You can call us to request one at 1-800-772-1213 (TTY 1-800-325-0778), Monday through Friday from 8:00 a.m. to 7:00 p.m.

You should fill out Form SSA-44 if you experience any life-changing event that reduces your income. Life-changing events that qualify are marriage, divorce, death of a spouse, work stoppage, work reduction, loss of income-producing property, loss of pension income and employer settlement payment.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232