TN 2 (04-99)

DI 52510.095 Exhibits of Goodnight Court Case

Exhibit 1 - Goodnight Potential Class Member Notice
Exhibit 2 - Goodnight Reply Form
Exhibit 3 - Goodnight Court Case Flag/Alert
Exhibit 4 - Court Case Folder Retrieval Worksheet
Exhibit 5 - Unfavorable Decision on Goodnight Class Membership Notice
Exhibit 6 - Goodnight Good Cause Denial Notice
Exhibit 7 - Goodnight SSN Verification Notice
Exhibit 8 - Goodnight Screening Sheet and Instructions

Exhibit 1- Goodnight Potential Class Member Notice

SOCIAL SECURITY ADMINISTRATION

Important Information

 DATE:
 CLAIM NUMBER:
 DOC:
 FO ADDRESS:
 Telephone:

 

READ CAREFULLY - PLEASE RESPOND TO THIS NOTICE WITHIN 90 DAYS

 

We are writing to let you know about a court case called Goodnight v. Apfel. This court case involves certain claims denied by the Utah Disability Determination Services during the period January 1, 1991, through February 20, 1994. Because of this case, you may ask us to review our earlier denial of your disability claim.

WHAT YOU NEED TO DO

You can ask us to look at your claim again. If you want us to do so, please fill out the enclosed reply form and send it to us within 90 days from the day you receive this notice. If you do not return the reply form, we may not be able to review your claim again.

IF YOU NOW GET MONEY FROM SOCIAL SECURITY

Even if you now get money from Social Security, we may owe you still more. If you request review, this will not affect any benefits you may currently be receiving. Return the reply form within 90 days from the day you receive this notice to ask us to review your earlier claim.

IF YOU HAVE ANY QUESTIONS

If you have any questions, you may contact your local Social Security office. The address and telephone number are printed at the top of this notice. If you call or visit a Social Security office, please have this notice with you. It will help us answer your question(s). You may also call us toll free at 1-800-772-1213 if you have any questions.

Additionally, if you have someone helping you with your claim, you should contact him/her. You or your representative may also contact the attorney in the Goodnight case:

Brent V. Manning
Manning Curtis Bradshaw & Bednar, LLC
3rd Floor, New House Building
10 Exchange Place
Salt Lake City, Utah 84111
Telephone (801) 363-5678

Si usted habla espanol y no entiende esta carta, favor de llevarla a la oficina de Seguro Social arriba mencionada para que se la expliquen.

 

Enclosures:
Reply Form and Envelope

Exhibit 2- Goodnight Reply Form

SOCIAL SECURITY ADMINISTRATION

GOODNIGHT V. APFEL REPLY FORM

IMPORTANT
RETURN THIS FORM WITHIN 90 DAYS TO REQUEST REVIEW OF YOUR GOODNIGHT CLAIM

Name

DOC:

Date:

Address

M2

Social Security NO:

City, State ZIP

 

Key Code:

   

Reference  :
Claim Number(s):

IF YOU WANT YOUR CLAIM REVIEWED, PLEASE SIGN AND DATE THIS FORM. YOU MUST ALSO FILL IN THE FOLLOWING INFORMATION AND RETURN THE FORM IN THE SELF-ADDRESSED, PRE-PAID ENVELOPE.

SIGNATURE                     

DATE                 

Enter the area code and the telephone number where we can call you.

 

(AREA CODE)                TELEPHONE NUMBER                     

WHAT YOU SHOULD DO IF YOUR ADDRESS HAS CHANGED

 

[ ]  Check this block only if your address is different than shown above, and enter your correct address.

 

ADDRESS  (NUMBER AND STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)

                                                                     

CITY and STATE                    ZIP CODE

 

PLEASE NOTIFY SSA IF YOUR ADDRESS CHANGES AFTER YOU MAIL THIS RESPONDER FORM.

SIGNATURE                     

DATE                 

Privacy Act Notice

The Social Security Act (Sections 205(a) of title II, 702 of title VII, 1631(e)(1)(A) and (B) of title XVI, and 1869(b)(1) and (c) of title XVIII) allows us to collect the information on this form. We will use the information to process your claim. You do not have to give us this information, but without it we may not be able to process your claim. Information may be disclosed to another person or to another governmental agency for the administration of the Social Security program or for the administration of programs requiring coordination with the Social Security Administration. Explanations about these and other reasons why information you provided us may be used or given out are available in Social Security Offices. If you want to learn more about this, contact any Social Security office.

Exhibit 3- Goodnight Court Case Flag/Alert

 

GOODNIGHT COURT CASE FLAG/ALERT

 

TITLE:       CATEGORY:

REVIEW OFFICE          PSC      MFT       DOC       ALERT DATE

 

              BOAN or PAN            NAME

 

 

             CAN OR HUN             RESPONSE DATE     TOE

 

 

TITLE    CFL     CFL DATE      ACN       PAYEE ADDRESS

II

XVI

 

 

SHIP TO ADDRESS:

 

 

 

 

If claim is pending in ODAR, ship folder to:

 

Office of Disability Adjudication and Review
Office of Appellate Operations (OAO)
One Skyline Tower, Suite 701
5107 Leesburg Pike
Falls Church, VA 22041-3200
ATTN: OAO Class Action Coordinator
(Case Locator Code 5001)

Exhibit 4- Court Case Folder Retrieval Worksheet

 

COURT CASE FOLDER RETRIEVAL WORKSHEET

 

1. Court Case Name         

Listing Code         

2. CAN/HUN             

BOAN/PAN         

   Claimant's Name                

3. a.

SOURCE/QUERY

RESPONSE*

DATE

SOURCE/QUERY

RESPONSE*

DATE

 

SSR/STALE

         

provided

OHAQ

          

provided

 

AR-25

         

provided

DDSQ

          

        

 

ODIO OVERNIGHT

         

provided

BDIQ

          

        

 

FACT

         

provided

SSID CCTL

          

        

  b.

ODIO SPEC SEARCH***

         

        

PCACS

          

        

  c.

PSC SPEC SEARCH***

         

        

   

 4. LIST OF CLAIMS SEARCHED

 
CAN (BIC)/HUN (ID)

APPL
DATE**

ALLEGED
ONSET**

      DECISION DATE**
DENIAL   TERM   ALLOW

 
RESULTS***

     
     
     
     
     
     
     
  *

Response should be YES/NIF (Not In File or No Record)/NA (Not Applicable).

 **

Show UNK if date cannot be determined.

***

Y = Medical evidence in folder; N = No medical evidence in folder or no folder located; D = Folder destroyed.

 

REMARKS:

5. All item 3. sources have been checked — see reverse for documentation — search ended.

     
Signature Position/Location Date

FOLDER SEARCH DOCUMENTATION

a. Alert CAN/HUN Folders

SOURCE/
QUERY
CONTACT
DATE
CONTACT LOCATION*PHONE/FAX #
OR ADM
MSG RI
CONTACT PERSON**SEARCH
RESULTS
      

 

 

 

 

 

 

 

 

 

 

 

b. Cross Reference Folders

SSN: (1)                

 

(2)                

 

(3)                

SOURCE/
QUERY
CONTACT
DATE
CONTACT LOCATION*PHONE/FAX #
OR ADM
MSG RI
CONTACT PERSON**SEARCH
RESULTS
      

 

 

 

 

 

 

 *

Show (T) beside phone #, if telephone; show (F), if FAX.

**

Y = Medical evidence in folder; N = No medical evidence in folder or no folder located; D = Folder destroyed.

Exhibit 5- Unfavorable Decision on Goodnight Class Membership Notice

SOCIAL SECURITY ADMINISTRATION

Important Information

 DATE:
 CLAIM NUMBER:
 DOC:
 FO ADDRESS:
 Telephone:

 

READ CAREFULLY - PLEASE RESPOND TO THIS NOTICE WITHIN 90 DAYS

 

We are writing to tell you that we received your request to review your earlier claim for disability benefits under the Goodnight court case. We have looked at your case and have decided that you are not eligible to have your claim reviewed. This means that we will not review our earlier decision.

A copy of this letter is being sent to your representative of record, if known, and the attorney for the Goodnight court case.

You may contact the class attorney in this case to obtain their assistance, if you think our decision is wrong. They will answer without charge your questions about eligibility for having your claim reviewed. The attorney's name, address, and telephone number is as follows:

Brent V. Manning
Manning Curtis Bradshaw & Bednar, LLC
3rd Floor, New House Building
10 Exchange Place
Salt Lake City, Utah 84111
Telephone (801) 363-5678

Reason For The Unfavorable Decision

You are not eligible to have your claim reviewed under the Goodnight court case because:

     

  1. Your claim was not denied by the Utah DDS during the period January 1, 1991, through February 20, 1994.

     

  1. Your claim was denied for a non-medical reason.

     

  1. The Form SSA-831-U3/C3 was not signed by either Manya Atiya, M.D. or Rebecca Dalisay, M.D.

     

  1. You appealed the denial of your Goodnight claim to an Administrative Law Judge, the Appeals Council or to court.

     

  1. You received a subsequent award of benefits with respect to the same period of time at issue in your Goodnight claim.

     

  1. You received a disability determination after February 20, 1994, that covered the same time period as your Goodnight claim.

     

  1. Your disability claim file contains a Psychiatric Review Technique Form (PRTF), SSA-4734-F4 SUP and Mental Residual Functional Capacity (MRFC) Form, SSA-2506-BK each completed in its entirety by a Utah DDS psychiatrist or psychologist employed by the Utah DDS during the period January 1, 1991 - February 20, 1994.

 

We Are Not Deciding If You Are Disabled

It is important for you to know that we are not making a decision about whether you are disabled. We are deciding only that you are not entitled to a review of your claim under the Goodnight court case. If you do not agree with this decision, you have 60 days after receiving this notice to notify class counsel, at the address listed above, that you want to protest this decision and explain your reason(s) why.

If You Think You Are Disabled Now

If you are not currently receiving disability payments and you think you are disabled now, you may file a new application. A new application is not the same as asking us to review your claim under Goodnight . In the new application you may not be able to receive disability benefits for the period of time you asked for in your prior claim. If you decide to file a new application, contact any Social Security office.

If You Have Any Questions

If you have any questions, you may contact the class attorney at the address above or your local Social Security office. The Social Security address and telephone number are printed at the top of this letter. You may also call us toll free at 1-800-772-1213 if you have any questions. If you call or visit a Social Security office, please have this letter with you. It will help us answer your questions.

Si usted habla espanol y no entiende esta carta, favor de llevarla a la oficina de Seguro Social arriba mencionada para que se la expliquen.

 

cc:
Brent V. Manning
Manning Curtis Bradshaw & Bednar, LLC

Exhibit 6- Goodnight Good Cause Denial Notice

 

SOCIAL SECURITY ADMINISTRATION

Important Information

 DATE:
 CLAIM NUMBER:
 DOC:
 (Field Office Return Address):
 (Field Office Phone Number):
 Telephone:

 

 

On            , we sent you a letter about a court case called Goodnight v. Apfel . In that letter we said that you could ask us to review your prior disability claim, and that this could result in payment of disability benefits to you. We notified you that you had to reply to the letter within 90 days from the date you received the notice, if you wanted us to review your claim. Our records show that you did not ask for review until         .

Under certain conditions, we can extend the time limit for you to request review. However, based on the facts that you gave us, we are unable to extend the time limit in your case. Accordingly, we cannot review your claim under the Goodnight v. Apfel court case.

 

If Your Have Any Questions

If you have any questions, you may contact your local Social Security office. The address and telephone number are printed at the top of this notice. If you call or visit a Social Security office, please have this letter with you. It will help us answer your question(s). You may also call us toll free at 1-800-772-1213 if you have any questions. If you have someone helping you with your claim, you should contact him/her. You or your representative may also contact the class attorney in the Goodnight case:

Brent V. Manning
Manning Curtis Bradshaw & Bednar, LLC
3rd Floor, New House Building
10 Exchange Place
Salt Lake City, Utah 84111
Telephone (801) 363-5678

Si usted habla espanol y no entiende esta carta, favor de llevarla a la oficina de Seguro Social arriba mencionada para que se la expliquen.

 

 

CC:
Brent V. Manning
Manning Curtis Bradshaw & Bednar, LLC

Exhibit 7 - Goodnight SSN Verification Notice

SOCIAL SECURITY ADMINISTRATION

Important Information

 

Date:                         

 

DOC:                      

 

FO Address:                      

 

FO Telephone:                      

 

Claim Number:          -       -              

 

You have asked us to review your claim for Social Security and/or Supplemental Security Income Disability benefits under the Goodnight court case. We have been unable to do so because we have no record that you ever filed an application for Social Security disability benefits or Supplemental Security Income disability benefits.

You might have given us the wrong Social Security number when you told us that you wanted to have your claim reviewed under the Goodnight court case. If you gave us the wrong number, that would explain why we have not been able to find a record of your claim. Please check your Social Security number carefully, and compare it to the following number. The number you gave us is                              . If this number is wrong, please write your correct Social Security number on the line above, marked “Claim Number.” Or, if you asked for Social Security benefits on someone else's record, please write that person's Social Security number on the line above, marked “Claim Number.” Return this letter in the enclosed envelope.

If you do not give us a new Social Security number, but you have evidence which shows that you filed a claim, please take the evidence, along with this letter, to your local Social Security office. We will take no further action on your request for review under the Goodnight court case. Please respond to this notice within 30 days from the date of this notice.

If You Have Other Questions

If you have any questions, you should call, write or visit any Social Security office. If you visit a Social Security office, please bring this letter with you. It will help us answer your questions. If you have someone helping you with your claim, you should contact him/her.

If You Have a Legal Representative or Would Like to Obtain One

You or your representative may also contact the attorney in this case. If you would like to obtain a legal representative, you may contact the attorney in this case. The attorney's name, address, and telephone number are as follows:

Brent V. Manning
Manning Curtis Bradshaw & Bednar, LLC
3rd Floor, New House Building
10 Exchange Place
Salt Lake City, Utah 84111
Telephone (801) 363-5678

Si usted habla espanol y no entiende esta carta, favor de llevarla a la oficina de Seguro Social arriba mencionada para que se la expliquen.

 

Enclosure:
Postage-paid Envelope

 

CC:
Brent V. Manning
Manning Curtis Bradshaw & Bednar, LLC

Exhibit 8 - Goodnight Screening Sheet and Instructions

G-SSA-307-1

Printer Friendly Version

 

G-SSA-307-2

Printer Friendly Version


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0452510095
DI 52510.095 - Exhibits of Goodnight Court Case - 02/05/2013
Batch run: 02/05/2013
Rev:02/05/2013