We are writing to you on behalf of the Social Security Administration in reference
to your [disability insurance benefits / Supplemental Security Income disability payments
/ disability insurance benefits and Supplemental Security Income disability payments].
We may be required by law to determine that you are not entitled to the benefits you
are currently receiving.
In order to get benefits, you must follow treatment prescribed by your medical source,
if this treatment is expected to restore your ability to work. If you do not follow
the prescribed treatment without a good reason, we will not find you disabled, or
if you are already receiving benefits, we will stop paying you benefits.
The evidence now in your file indicates that you are failing, without good cause,
to follow prescribed treatment, [tell what treatment—e.g., back surgery, eye surgery]
that could be expected to restore your ability to work. If you have information or
evidence about this prescribed treatment and why you are not following it, it is important
that you let us know within 30 days.
If we do not hear from you within 30 days of the date of this notice, we will make
a determination based on the evidence already on file, and your [claim will be denied/benefits
will be ceased]. Such a determination may also result in the loss of future rights
or a decrease in the amount of benefits payable.
If you have any questions, please write to [insert title and address of DDS] as soon
as possible or call [name of contact and phone number].