Please explain why you disagree with our decision. Do you have additional information to support your appeal?
Preparation time: to give you time to prepare for the hearing, we allow at least 20 days between the date of your request and the date we schedule the hearing.
Hearing: if you want a hearing, you will receive a notice with the date and time of the hearing; please complete questions 10 through 13.
No hearing: you will receive a decision based on the information available and any additional information you provide.
Signing: if you cannot sign, a representative may sign for you.
Additional information: send the additional information with this form to the address shown on the bottom of page 2.
| Question | Answer |
|---|---|
| Form Name | Form SSA-1021 |
| Form Length | 4 pages |
| Fillable? | Yes |
| Fillable fields | 67 |
| Avg. time to fill out | 12 min |
| Edition | 02-2025 |
| Where to send | Social Security Administration, Wilkes-Barre Direct Operations Center, P.O. Box 1030, Wilkes-Barre, PA 18767-1030 |
| Other names | SSA-1021, SSA 1021, Form 1021, 1021 form, Form SSA-1021, Appeal of Determination for Extra Help with Medicare Prescription Drug Plan Costs |
| Official source | Form SSA-1021 (Rev 02-2025), Social Security Administration |
Form Ssa 1021 isn’t the one you’re looking for?