TN 11 (03-04)

NL 00705.354 Continuing Disability Review (CDR) Come-In Notice

Social Security Administration

Supplemental Security Income

Notice of Continuing Disability Review  

 

Street Address

City, State, ZIP

Phone:

Office Hours:

Date:

Claim Number: xxx-99-xxxxxDC 

 

John Smith for

Jane Smith

101 Main Street

Any City, ST 00001 

 

 

IMPORTANT NOTICE

YOU MUST CONTACT US OR JANE SMITH'S SSI MAY STOP 

 

We must review the cases of children who are receiving Supplemental Security Income (SSI) based on disability to make sure they are still disabled under our rules. Our rules require us to review, at least once every three years, the cases of children whose health we think may improve. We may also review cases at other times, even if we do not think that a child's health may improve. 

 

We are writing to let you know that we are starting to review Jane Smith's SSI case. We have enclosed a pamphlet, “How We Decide If You Are Still Disabled,” that will tell you more about the review. 

 

What You Need To Do Now 

 

Choice 1

Please call us and ask for. 

 

 

See Next Page 

 

999-99-9999D Page 2 of 4 

 

Choice 2 

 

We would like you to come to our office on ______________. 

 

When you come in, please ask for ________________________. 

If you cannot come in on the date shown or would prefer to talk with us by telephone, please call us as soon as possible. The office address, telephone number, and office hours are shown above. 

 

The Information We Will Need 

 

When you come in or call, please try to have all of the following things with you. Even if you do not have everything, you still must call us or come in. We will help you get anything you do not have. 

 

  • This letter.

  • The enclosed form(s). Please be sure to complete as much of the form(s) as you can before you come in or call. 

  • The names of any medicines she uses.

  • Any information that shows her condition, such as information about:

    • hospital stays and/or surgeries, including the dates and reasons;

    • visits to doctors and/or clinics, including the dates and reasons;

    • counseling and/or therapy;

    • schools and/or special classes or tutoring; and

    • teachers and/or counselors who have knowledge of her condition. 

 

We may ask for other information later. 

 

***(NOTE: Do NOT use the following language if the child is his/her own payee.) 

 

We May Ask You To Show That Jane Smith Receives Treatmen

 

Before we review Jane Smith's case, we may also ask you to show proof that she is and has been receiving treatment that is medically necessary and available for her condition. Before we ask for this proof, we will consider the nature of her condition. If you do not show proof of treatment when we ask you, and you do not have a good reason why she is not receiving treatment, we may stop making payments to you and select another payee if it is in her best interests. If she is old enough, we may pay her directly. 

 

See Next Page 

 

999-99-9999DC Page 3 of 4 

 

How We Decide If She Is Disabled 

 

Doctors and other trained staff will decide for us if:

  • her condition has improved, and if

  • she is still disabled under our rules. 

 

We Will Let You Know What We Decide 

 

When we decide, we will write and let you know our decision. Our letter will tell you whether she is still disabled under our rules. 

 

We may find that she is no longer disabled under our rules and her SSI could stop. If this happens, you can appeal our decision. If you appeal our decision, you can also choose to have us continue to pay you until we decide the appeal. 

 

If We Do Not Hear From You 

 

We may stop Jane Smith's SSI if you do not answer this letter by

(Month/Day/Year) or contact us by this date to tell us why we have not heard from you. Before we stop her SSI, we will send you another letter to explain our decision. The letter will also explain your right to appeal the decision and how to continue getting payments during the appeal. 

 

Information About Medical Assistance 

 

If Jane Smith's SSI stops, any medical assistance she has that is based on SSI may also stop. If this happens, your medical assistance agency should contact you, or you can call them to see if you qualify for continued medical assistance. You should know that children do not have to be disabled to qualify for medical assistance. Many children may still qualify for medical assistance if they live in households that meet the income and resource rules for SSI. 

 

You may also be able to receive help to pay Jane Smith's medical bills through the Children's Health Insurance Program (CHIP) in your State. For more information about CHIP in your State, call toll-free 1-877-KIDS NOW or 1-877-543-7669. 

 

If You Have Any Questions 

 

We will be glad to answer any questions that you have. Whether we talk to you by phone or in person, 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 

 

See Next Page 

 

999-99-9999DC Page 4 of 4 

 

you qualify. Our office has a list of groups that can help you. If you get someone to help you, you should let us know. 

 

Remember, if you cannot come in or would prefer to talk to us by phone, please call us right away. Our phone number is shown on the first page of this letter. 

 

 

 

Field Office Manager 

 

Enclosure(s)

SSA Pub. No. 05-10053

[The enclosures may include and of the following:

Form SSA-3881, Questionnaire for Children Claiming SSI Benefits

Form SSA-827, Authorization for Source to Release Information to the Social

Security Administration] 

 

Notice Language

Fill-ins

IMPORTANT NOTICE

YOU MUST CONTACT US OR (1) SSI MAY STOP 

 

We must review the cases of children who are receiving Supplemental Security Income (SSI) based on disability to make sure they are still disabled under our rules. Our rules require us to review the cases of children whose health we think may improve at least once every three years. We may also review cases at other times, even if we do not think that a child's health may improve. 

 

We are writing to let you know that we are starting to review (2) SSI case. We have enclosed a pamphlet, “How We Decide If You Are Still Disabled,” that will tell you more about the review. 

 

Fill-ins: 

 

  1. Choice 1: Recipient's name (possessive)

    Choice 2: Your 

     

  2. Choice 1: Recipient's name (possessive)

    Choice 2: your 

 

What You Need To Do Now 

 

Fill-ins:

 

  1. Choice 1:

    Please call us and ask for (name of FO employee). 

     

  2. Choice 2:

    We would like you to come to our office on (date and time of appointment).

    When you come in, please ask for (name of FO employee). 

  

If you cannot come in on the date shown or would prefer to talk with us by telephone, please call us as soon as possible. The office address, telephone number, and office hours are shown above. 

 

The Information We Will Need  

  

When you come in or call, please try to have all of the following things with you. Even if you do not have everything, you still must call us or come in. We will help you get anything you do not have. 

 

  • This letter.

  • The enclosed form(s). Please be sure to complete as much of the form(s) as you

  • can before you come in or call.

  • The names of any medicines (1).

  • Any information that shows (2) condition, such as information about:

    • hospital stays and/or surgeries, including the dates and reasons;

    • visits to doctors and/or clinics, including the dates and reasons;

    • counseling and/or therapy;

    • schools and/or special classes or tutoring; and

    • teachers and/or counselors who have knowledge of (3) condition. 

 

We may ask for other information later. 

  

  1. Choice 1: he uses

    Choice 2: she uses

    Choice 3: you use  

     

  2. Choice 1: his

    Choice 2: her

    Choice 3: your 

     

  3. Choice 1: his

    Choice 2: her

    Choice 3: your 

 

***(NOTE: Do NOT use the following language if the child is his/her own payee.) 

 

We May Ask You To Show That (1) Receives Treatment 

 

Before we review (2) case, we may also ask you to show proof that (3) is and has been receiving treatment that is medically necessary and available for (4) condition. Before we ask for this proof, we will consider the nature of (5) condition. If you do not show proof of treatment when we ask you, and you do not have a good reason why (6) is not receiving treatment, we may stop making payments to you and select another payee if it is in (7) best interests. If (8) is old enough, we may pay (9) directly. 

 

  1. Choice 1: Recipient's name (possessive) 

     

  2. Choice 1: Recipient's name (possessive) 

     

  3. Choice 1: he

    Choice 2: she 

     

  4. Choice 1: his

    Choice 2: her 

     

  5. Choice 1: his

    Choice 2: her 

     

  6. Choice 1: he

    Choice 2: she 

     

  7. Choice 1: his

    Choice 2: her 

     

  8. Choice 1: he

    Choice 2: she 

     

  9. Choice 1: him

    Choice 2: her 

 

How We Decide If (1) Disabled 

 

Doctors and other trained staff will decide for us if: 

 

  • (2) condition has improved, and if

  • (3) still disabled under our rules. 

 

  1. Choice 1: She Is

    Choice 2: He Is

    Choice 3: You Are 

      

  2. Choice 1: his

    Choice 2: her

    Choice 3: your 

     

  3. Choice 1: he is

    Choice 2: she is

    Choice 3: you are 

 

We Will Let You Know What We Decide 

 

When we decide, we will write and let you know our decision. Our letter will tell you whether (1) still disabled under our rules. 

 

We may find that (2) no longer disabled under our rules and (3) SSI could stop. If this happens, you can appeal our decision. If you appeal our decision, you can also choose to have us continue to pay you until we decide the appeal. 

 

  1. Choice 1: he is

    Choice 2: she is

    Choice 3: you are 

     

  2. Choice 1: he is

    Choice 2: she is

    Choice 3: you are

  3. Choice 1: his

    Choice 2: her

    Choice 3: your 

     

If We Do Not Hear From You 

 

We may stop (1) SSI if you do not answer this letter by (Month/Day/Year) or contact us by this date to tell us why we have not heard from you. Before we stop (2) SSI, we will send you another letter to explain our decision. The letter will also explain your right to appeal the decision and how to continue getting payments during the appeal. 

 

  1. Choice 1: Recipient's name (possessive)

    Choice 1: Recipient's name (possessive)

    Choice 2: your 

     

  2. Choice 1: his

    Choice 2: her

    Choice 3: your 

     

Information About Medical Assistance 

 

If (1) SSI stops, any medical assistance (2) that is based on SSI may also stop. If this happens, your medical assistance agency should contact you, or you can call them to see if