TN 33 (10-05)

DI 23570.115 Age 18 Disability Redetermination – Continuance Notice Language

A. Exhibit

Social Security Administration

Supplemental Security Income

Important Information

Date:

Claim Number: XXX-XX-XXXX

JOHN SMITH

STREET ADDRESS

CITY ST ZIP

Earlier we told you that we would review your case to decide if you are disabled under the disability rules for adults. We are writing to tell you that you will continue to receive Supplemental Security Income payments if you still meet all the other eligibility requirements. This is because you are disabled under the disability rules for adults. Also, if you are getting medical assistance based on SSI, your coverage should continue.

We Will Review Your Case Again

The doctors and other trained staff who decided that you are still disabled believe that your health may improve. Therefore, we will review your case again in about 3 years. We will send you a letter before we start your review.

Things To Remember

The decision we made on your case is based on information we have now. If this information changes, it could affect your SSI. For this reason, it is important that you report changes right away. Be sure to tell us about any of the following changes:

  • You go to work.

  • Your job, pay or work expenses change, if you are working now.

  • Your doctor says your health is better.

  • Your income, livings arrangements, or resources change.

If You Disagree With The Decision

If you disagree with the decision, you have the right to appeal. We will review your case again and consider 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 any appeal.

  • The 60 days start the day after you receive this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

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

  • You have to ask for an appeal in writing. We will ask you to sign Form SSA-561-U2, called “Request for Reconsideration.” Contact one of our offices if you want help.

How the Appeal Works

You have the right to review the facts in your case. You can give us more facts to add to your file. Then we will decide your case again. You will not meet the person who will decide your case.

If You Want Help With Your Appeal

You can have a friend, lawyer, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it.

If You Have Any Questions

If you have any questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at XXX-XXX-XXXX. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

Street Address

City, ST ZIP

If you do call or visit an office, please have this letter with you. It will help us answer your questions.

Regional Commissioner

B. Paragraphs with Fill-ins

1. Paragraph 1 (Lead-in Paragraph)

Earlier we wrote to tell you that we would review (1) disability case to decide if (2) disabled under the disability rules for adults. We are writing to tell you that (3) will continue to receive Supplemental Security Income payments if (4) all the other eligibility requirements. This is because (5) disabled under the disability rules for adults. Also if (6) getting (7) based on SSI, (8) coverage should continue.

Fill-ins

  1. Choice 1: your

    Choice 2: recipient's name

  2. Choice 1: you are

    Choice 2: she is

    Choice 3: he is

  3. Choice 1: you

    Choice 2: he

    Choice 2: she

  4. Choice 1: you still meet

    Choice 2: she still meets

    Choice 3: he still meets

  5. Choice 1: you are

    Choice 2: she is

    Choice 3: he is

  6. Choice 1: you are

    Choice 2: she is

    Choice 3: he is

  7. Choice 1: medical assistance

    Choice 2: Medicaid

    Choice 3: AHCCCS (for Arizona)

    Choice 4: MediCal (for California)

  8. Choice 1: your

    Choice 2: her

    Choice 3: his

2. Paragraph 2 (Medical Reexamination Diary)

We Will Review [Your/Recipient name, possessive] Case Again

Option 1 (MIE diary established)

The doctors and other trained staff who decided that (1) still disabled expect (2) health to improve. Therefore, we will review (3) case again in (4). We will send you a letter before we start the review.

Fill-ins

  1. Choice 1: you are

    Choice 2: she is

    Choice 3: he is

  2. Choice 1: your

    Choice 2: her

    Choice 3: his

  3. Choice 1: your

    Choice 2: her

    Choice 3: his

  4. Month/Year

Option 2 (MINE diary established)

Doctors and other trained staff decided that (1) still disabled. And we realize that (2) health may not improve. But we must review all disability cases. Therefore, we will review (3) case again in 5 to 7 years. We will send you a letter before we start the review.

Fill-ins

  1. Choice 1: you are

    Choice 2: she is

    Choice 3: he is

  2. Choice 1: your

    Choice 2: her

    Choice 3: his

  3. Choice 1: your

    Choice 2: her

    Choice 3: his

Option 3 (MIP diary established)

The doctors and other trained staff who decided that (1) still disabled believe that (2) health may improve. Therefore, we will review (3) case again in about 3 years. We will send you a letter before we start the review.

Fill-ins

  1. Choice 1: you are
    Choice 2: she is
    Choice 3: he is

  2. Choice 1: your

    Choice 2: her

    Choice 3: his

  3. Choice 1: your

    Choice 2: her

    Choice 3: his

3. Paragraph 3 (Reporting Reminders)

Things To Remember

The decision we made on (1) case is based on information we have now. If this information changes, it could affect (2) SSI. For this reason, it is important that you report changes right away. Be sure to tell us about any of the following changes.

  • (3) to work.

  • (4) job, pay or work expenses change, if (5) working now.

  • (6) doctor says (7) health is better.

  • (8) income or resources change.

    Fill-ins:

    1. Choice 1: your

      Choice 2: her

      Choice 3: his

    2. Choice 1: your

      Choice 2: her

      Choice 3: his

    3. Choice 1: You go

      Choice 2: She goes

      Choice 3: He goes

    4. Choice 1: Your

      Choice 2: Her

      Choice 3: His

    5. Choice 1: you are

      Choice 2: she is

      Choice 3: he is

    6. Choice 1: Your

      Choice 2: Her

      Choice 3: His

    7. Choice 1: your

      Choice 2: her

      Choice 3: his

    8. Choice 1: Your

      Choice 2: Her

      Choice 3: His

4. Paragraph 4 (Appeal Rights)

If You Disagree With The Decision

If you disagree with the decision, you have the right to appeal. We will review your case again and consider 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 any appeal.

  • The 60 days start the day after you receive this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

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

  • You have to ask for an appeal in writing. We will ask you to sign Form SSA-561-U2, called “Request for Reconsideration.” Contact one of our offices if you want help.

5. Paragraph 5 (Reconsideration Process)

How the Appeal Works

You have the right to review the facts in your case. You can give us more facts to add to your file. Then we will decide your case again. You will not meet the person who will decide your case.

6. Paragraph 6 (Right to Representation)

If You Want Help With Your Appeal

You can have a friend, lawyer, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it.

7. Paragraph 7 (FO Referral)

If You Have Any Questions

If you have any questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at (1). We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

(2)

If you do call or visit an office, please have this letter with you. It will help us answer your questions.

Fill-ins:

  1. FO Phone Number from DOORS

  2. FO Street Address from DOORS

8. Name, Title, and Signature Requirements

Follow NL 00601.003.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0423570115
DI 23570.115 - Age 18 Disability Redetermination - Continuance Notice Language - 12/06/2012
Batch run: 12/06/2012
Rev:12/06/2012