TN 20 (09-90)

DI 28055.050 Model Language: Impairment Severity Cessation Notice - Exhibit

We are writing to tell you that we have looked at your case to see if your health problems are still disabling. After looking at all of the information in your case carefully, we found that you are not disabled under our rules as of (month/year).

If You Are Receiving Benefits

• •

  If you are receiving payments, they will end. We will write you later if we owe you any back payments or you are overpaid.

• •

  If you have Medicare, this coverage will also end.

Do You Think We Are Wrong?

If you think we are wrong, you have the right to appeal. We will correct any mistakes and we will look at any new facts you have. A person who did not make the first decision will decide your case.

• •

  You have 60 days to ask for a appeal.

• •

  The 60 days start the day after you receive this letter.

• •

  You must have a good reason if you wait more than 60 days to ask for an appeal.

Appeal in 10 Days to Keep Receiving Your Payment and/or Medicare

You have only 10 days to ask up to continue your benefits during your appeal.

• •

  The 10 days start the day after you get this letter.

• •

  You can ask us to keep paying you and your family and/or
  continue your Medicare.

• •

  If you lose your appeal, you might have to pay back some or all of this money, but you will not have to pay back Medicare.

How an Appeal Works

A Disability Hearing Officer will decide your appeal. We will call this person a DHO in the rest of our letter. The DHO will meet with you before making the decision on your appeal. The meeting works like this.

• •

  The DHO will write you about the time and place for the meeting.

• •

  You can look at your file before the meeting.

• •

  You can tell the DHO why you think you are still disabled. You can give the DHO more facts. And you can bring people to say why you are disabled.

• •

  You can have the DHO ask people to come to the meeting and bring important papers. You can question these people at the meeting.

• •

  You do not have to go to the meeting in person. If you do not want to go, you can give the DHO more facts you may have. The DHO will decide your case using these facts and what is now in your file. But if you go to the meeting, it may help the DHO decide your case.

If You Want Help With Your Appeal

You may want help from a friend, lawyer or someone elso. There are groups that can find you a lawyer. Some can give you a free lawyer. We can give you the names of these groups.

If Your Health Gets Worse

If you health gets worse and you feel that you are disabled please get in touch with us, you may be able to receive benefits again.

If You Have Any Questions

If you have any questions, you should call, write or visit any Social Security office. If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

Enclosures:

Explanation of Determination

SSA Pub. No. 05-10058