DI 12095.155 Model Language SSI Notice of Change - Reinstatement Notice to DAA Recipient Who Was
in Noncompliance with Treatment Requirement
Supplemental Security Income
Notice of Change
Department of Health and Human Services
Social Security Administration
We have received information that affects your payments (or those of the individual
named above, on whose behalf you applied to receive payments). Based on this information,
we are taking the following action:
Since you are (undergoing) (willing to have) appropriate and available treament for your condition of (drug addiction) (alcoholism) (drug addiction and alcoholism) you are eligible to receive Supplemental Security Income payments.
You continue to be subject to the representative payee requirement. Therefore, your
payments must continue to be made to another person on your behalf.
You must report to us if -
You go to work regardless of how much you earn, or if there is any increase in your
work duties, hours worked, or earnings; or
Your medical condition improves. These changes can affect our finding that you are
This information is also being sent to (name of representative payee).
TURN THIS OVER IF YOU THINK WE ARE WRONG
Form SSA-L8151-U2 (6-83)
Use prior editions until exhausted
YOUR RIGHT TO APPEAL
If you think we are wrong, you have the right to appeal. If you appeal, we will review
our decision. If we made a mistake, we will fix it. If you have any questions, 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.
HOW TO APPEAL
There are two different kinds of appeals. You can pick the one you want unless you
do not agree with what we decided about your medical condition. Then, the only appeal
you can have is a case review. 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 two kinds of appeals:
You can give us more facts to add to your file. Then, we will decide your case again.
You will not meet with the person who will decide your case. This is the only kind
of appeal you can have if you do not agree with what we decided about your medical
You will meet with the person who will decide your case. You can tell that person
why you think you are right. You can also give us more facts to help prove you are
right. You can bring other people to help explain your case. You can pick this kind
of appeal unless you do not agree with what we decided about your medical condition.
REMEMBER, YOU PICK THE KIND OF APPEAL YOU WANT. BUT, IF YOU APPEAR IN PERSON, IT MAY
HELP US TO DECIDE YOUR CASE.
TO APPEAL, YOU MUST MAKE A REQUEST IN WRITING. Be sure to tell us your name, social
security number, and why you think we are wrong. Also tell us what kind of appeal
you want-CASE REVIEW OR INFORMAL CONFERENCE. If you cannot write to us, call our office
or come in and someone will help you.
There are groups that can help you with your appeal. Some groups may be able to give
you the name of a lawyer who will help you for free. Let us know if you want the names
of these groups.
You have other rights because you are eligible under the supplemental security income
program. There are also some things you must do. The enclosed booklet tells you what
you should know. Please read this booklet and keep it in case you have questions later.