BASIC (03-86)

DI 28065.035 Completion of Form SSA-833-U5

For the most part, completion of Form SSA-833-U5 is the same for felony/ prisoner cases as for any medical CDR determination. However, certain items require special entries as described below.

A. Item 1B - Case type

Check block FZ in continuance determination based on confinement-related impairment(s).

B. Item 24 - Remarks

Enter: “Prisoner Case - Resolution of CD issue required upon reinstatement of benefits.” This entry applies in continuances based on insufficient evidence because of confinement.

C. Item 29 - Notice Instructions

1. Continuances: Enter: SSA-L1013

2. Cessations: Enter: ODO/DL

D. Item 34 - List Number

In addition to any other applicable list numbers, enter one of the following as applicable:

1. 608 - Cessation in which a felony-related impairment is excluded from consideration.

2. 610 - Benefits suspended due to confinement

3. 623 - Prisoner Case. Freeze Only established.