TN 3 (04-12)
DI 28080.015 Sample Language for a Title II Continuing Disability Review Pre-determination Notice
We reviewed your record to see if you are still eligible for Social Security disability insurance benefits. To get benefits, you must be unable to do any substantial gainful activity. Substantial gainful is physical or mental work you can do for pay or profit. It can be full-time or part-time work.
Based on the information we have, we plan to decide that you can do substantial gainful activity starting in (date). A State agency, rather than the persons or agencies that gave us reports decided this. You will be eligible to receive benefits for (date) and for the next 2 months.
What You Should Do
Please write to us within 10 days if you have more information that you want us to consider. You can write to us at this address: DDS Name, Street, City and State, Zip Code.”
If We Do Not Hear From You
If we do not hear from you within 10 days, we will make our decision about your disability benefits based on the information we have. We will end you another letter when we make our final decision.
The Information We Have
We considered the following reports in addition to the evidence you gave us when you first filed for benefits:
Sawyer Memorial Hospital report of admission of 01/10/2010 to 02/06/2010, and outpatient records of 03/03/2010 to 06/17/2010. Greg Sweeney, M.D., report of 07/05/2010. “The information showed (1).”
(1) Include a brief statement describing the basis for the most recent favorable medical decision and the reason for the current medical review.
You say you still cannot work because (2).”
(2) Include a brief statement outlining the reasons the beneficiary gave for believing he or she is still disabled and whether or not he or she is still engaging in SGA.
Current reports show (3).”
(3) Describe current medical severity, medical improvement or exceptions to the medical improvement standard and ability to work.
Describe the work the claimant can do. (4)
(4) Include a brief statement, if appropriate, outlining the past job the beneficiary can do, or a statement that although the beneficiary cannot do past work, considering age, education, and past work experience, he/she has the capacity to do other kinds of work requiring less physical exertion.
If You Have Any Questions
Insert contact information including telephone number.
NOTE: In ceased prisoner cases, because we cannot consider the original impairment, the notice must include the Rider W message. See NL 00705.540, Prisoner Model Letter “W” – Felony and Non-Felony Related Impairments – DIB, CDB, DWB.