DI 12095.140 Model Language SSI Notice of Planned Action - Individual Does Not Agree With Appropriateness/Availability
Supplemental Security Income
Notice of Planned Action
Department of Health and Human Services
Social Security Administration
Social Security Number:
Your payments (or those of the individual named above) will be changed as follows:
Your payment will be stopped effective (date).
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
We informed you that the medical evidence in your claim shows that (drug addiction)
(alcoholism) 1/ contributes to the finding that you are disabled. Therefore, your payments must
be made to another person on your behalf. In addition, you must undergo any appropriate
treatment for your condition as a (drug addict) (alcoholic) 1/, if such treatment is available, in order to be eligible for payments. You have
failed to comply with the treatment requirement on the basis that you believe treatment
is not appropriate and/or available to you.
After further consideration of all the facts in your case, it has been determined
that treatnent for your condition as a (drug addict) (alcoholic) 1/ is appropriate and available. Since you are not complying with the treatment requirement,
the provisions of the law are not met and your payments will be stopped effective
This information is also being sent to (name of representative payee).
1/Use term(s) that applies
NOTE: Send a copy of this notice to the representative payee.
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
||Form SSA-L8155-U2 (2-82)
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
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
prove you're right. We can make them bring important papers about your case. We can
do this even if they don't want to help you. You can question these people at your
To appeal, you must fill out a form at one of our offices. It is called a Request
for Reconsideration, SSA-561-U2. On the form, YOU PICK THE KIND OF APPEAL YOU WANT. We'll help you fill it out.
There are groups that can help you with your appeal. Some can give you a free lawyer.
We can give you names of these groups.
||Form SSA-L8155-U2 (2-82)