Social Security Administration
Supplemental Security Income
Disability Redetermination Decision
Claim Number: XXX-XX-XXXX
CITY ST ZIP
Important Notice—Your SSI Will Stop
Earlier we told you that we were reviewing your case to see if you are disabled under
the definition of disability for adults. After reviewing all of the information carefully,
we have decided that you no longer qualify for Supplemental Security Income (SSI).
We urge you to read this entire letter. It includes important information about appeal
rights and Medicaid eligibility. It also explains how you can continue to receive
benefits if you appeal.
The Decision on Your Case
[Personalized Case Language (“PDN”)]
When Payments Will Stop
Under the disability rules for adults, you are no longer disabled as of (Month/Day/Year). You will get SSI for that month and the next two months. Your last SSI payment
will be for (Month/Year) as long as you continue to meet all other eligibility requirements until then.
Information About Medicaid
For information about any change in your Medicaid eligibility caused by this action,
you should get in touch with the county welfare office or social service agency.
You Have Important Appeal Rights
If you disagree with the decision, you have the right to appeal. We will review the
case and consider any new facts you have. A person who did not make the first decision
will decide the case.
You can ask for an appeal anytime within 60 days. But if you want to keep getting payments while we decide the case you must ask for
an appeal within the first 10 days.
The 60 days start the day after you get 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
You must have a good reason for waiting more than 60 days to ask for an appeal.
You have to ask for an appeal in writing. We will ask you to sign a form SSA-789-U4
called “Request for Reconsideration—Disability Cessation.” To get this form, contact one of our offices. Address(es) and phone number(s) are
shown on the last page of this letter. We can help you fill out the form.
Please read the enclosed pamphlet, “Your Right to Question the Decision Made on Your SSI Claim.” It contains more information about the appeal.
Appeal in 10 Days To Keep Getting Your Payment
The 10 days also start the day after you get 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
If you lose the appeal, you might have to pay back some or all of this money. However,
we may decide that you do not have to pay the money back.
How An Appeal Works
A Disability Hearing Officer will decide your SSI appeal. We will call this person
a DHO in the rest of our letter. The DHO will meet with you before making the decision
on the appeal. The meeting works like this.
The DHO will mail you a letter at least 20 days before the meeting to tell you its
date, time and place.
You can look at your file before the meeting.
You can tell the DHO the reasons you think you are still disabled. You should give
the DHO any information you think is missing from your file. You can bring someone
to represent you at the meeting. And you can bring people to explain the reasons you
You can have the DHO ask people to come to the meeting to speak about your disability
and bring important papers. You can question these people at the meeting.
You do not have to go the meeting in person. If you do not want to go, you can still
give the DHO more facts that you have. The DHO will decide the case using these facts,
and what is now in the file. But if you go to the meeting, it may help the DHO to
decide the case.
If You Want Help With Your Appeal
You can have a lawyer, friend, 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. The 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 Your Health Gets Worse
If your health gets worse, please get in touch with us. You may be able to get SSI
again. We can help you file a new application for SSI.
You have the right to file a new application at any time, but filing a new application
is not the same as appealing this decision. So, if you disagree with this decision,
you should ask for an appeal within 60 days.
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:
City, ST ZIP
If you do call or visit an office, please have this letter with you. It will help
us answer your questions. Also, if you plan to visit an office, you may call ahead
to make an appointment. This will help us serve you more quickly.
SSA Pub. No. 05-10090