DI 12095.125 Model Language SSI Notice of Planned Action - DA&A Provisions Apply
Model Language-SSI Notice of Planned Action to a Recipient from DO Informing Him of DA&A Provisions (to be used following CDI determination of continuance where DA&A requirements now Imposed but not previously applicab1e)
Supplemental Security Income
Notice of Planned Action
Department of Health and Human Services
Social Security Administration
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Social Security Number:
Your payments (or those of the individual named above) will be changed as follows:
Your payment will be stopped effective (date) .
You have been notified that (drug addiction) (alcoholism) 1 / contributes to the finding that you are still disabled. Under the law, a disabled person who is medically determined to be a drug addict or alcoholic must receive his supplemental security income payments through another person on his behalf. In addition, he must undergo any appropriate treatment for his condition as a drug addict or alcoholic, if such treatment is available, in order to be eligible for payments.
We want to discuss these provisions with you in greater detail and to obtain information from you which, will assist us in selecting a representative payee to receive your supplemental security income payments on your behalf. A decision will be made later as to whether appropriate treatment is available. Please contact this office within 10 days after receipt of this notice to arrange for an appointment. If you phone, please have this notice nearby so that you may refer to it. Please bring it with you if you visit the office.
If you do not provide information to assist us in selecting a representative payee to receive your supplemental security income payments for you, your payments will be stopped effective (date) (unless we otherwise have sufficient information to select a payee for you). If you believe the determination that (drug addiction) (alcoholism) 1/ contributes to the finding that you are disabled is not correct, you may request reconsideration as explained on the reverse of the notice.
1/ Use term(s) that applies
We won't change your check if you appeal within 10 days after getting this notice.
TURN THIS OVER if you think we're wrong
YOUR RIGHT TO APPEAL
Do you think we're wrong? If so, you have the right to appeal. If you appeal, we'll review our decision. We'll change mistakes. Do you have other questions? If so, get in touch with us. Please bring this notice with you if you come to a Social Security office.
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days, you must have a good excuse.
APPEAL IN 10 DAYS TO KEEP GETTING YOUR SAME CHECK
We won't change your check if you appeal within 10 days after getting this notice. You'll keep getting your same check until we decide your appeal. If you lose your appeal, you might have to pay some or all of this money back.
HOW TO APPEAL
There are three different ways to appeal. You can pick the one you want. The people in our offices can explain how these appeals work. You can have a lawyer, friend, or someone else help you with your appeal.
Here are the three ways to appeal:
You can give us more facts to add to your file. Then we'll decide your case again. You don't meet with the person who decides your case.
You'll meet with the person who will decide your case. You can tell that person why you think you're right. You can give us more facts to help prove you're right. You can bring other people to help explain your case.
This is a meeting like an informal conference. Plus, we can make people come to help