NL 00705.201 Reopening Notice 1 – Allowance to Denial – Title II
Disability
Allowance to Denial
–
Title
II
We are writing to you about (1) Social Security Disability Insurance (SSDI) benefits. We recently looked at (2) disability claim again to make sure our decision was correct. After reviewing all of the information carefully, we are changing our decision.
Based on our rules, we now find that (3) not disabled. Therefore, (4) claim is denied. You will get another letter soon about when (5) payments (6) will stop.
Fill-ins:
(1)
your/claimant’s name (possessive)
(2)
your/his/her
(3)
you are/claimant's name
is
(4)
your/claimant's name
(possessive)
(5)
your/his/her
(6) or Medicare/null
The Decision
See the enclosed Explanation.
Attach
the Personalized Disability Explanation (PDE)
language per DI 26530.020 and
DI 26530.055, including a list of the evidence, an explanation of what the evidence shows, and the
detailed, personalized reasons for the determination. For additional guidance, see Reopening of
Prior Determination DI 27536.015.
If concurrent claims are involved,
include :
This decision refers only to (1) SSDI benefits. You will get a separate letter about (2) Supplemental Security Income (SSI) payments.
Fill-ins:
(1)
your/his/her
(2)
your/his/her
(Universal
text identifier (UTI)
4054)
Who Decided
(1)
Case
Fill-in:
(1)
Your/His/Her
If DDS disability determination :
Doctors and other trained staff looked at this case and made this decision. They work for the State but used our rules.
If Federal disability determination :
Our doctors and other trained staff looked at this case and made this decision.
(UTI ALSC12)
If You Disagree With The Decision
(UTI ALS023 – modified to show the SSA-789 instead of the SSA-561)
NOTE: If the revision is due to a non-medical reason, such as work, show “SSA-561, called “Request
for Reconsideration” instead of the SSA-789. Do not include the language for the DHO hearing or
statutory benefit continuation.
If you do not agree with this decision, you have the right to appeal. A person who did not make the first decision will decide the case. We will review the case and look at any new facts you have. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in your favor.
•
You have 60 days to ask for an appeal.
•
The 60 days start the day after you receive 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 period.
•
You must have a good reason if you wait more than 60 days to ask for an appeal.
•
You must ask for an appeal in writing. Please use our "Request for Reconsideration - Disability Cessation" form, SSA-789. You can go to our website at https://www.ssa.gov/forms to locate this form. You can also contact us to request the form or if you need help filling out the form.
Do not
send the following caption and
paragraph below
(4059)
if there is a determination of fraud or similar fault since FSF precludes the payment of statutory
benefit continuation (SBC) .
Do not
send the following caption and paragraph if the
revision is due to a non-medical reason, such as work or other reason that precludes payment of SBC
(see DI 27540.025). However, a predetermination due process notice is needed.
(UTI
4059)
Appeal In 10 Days To Keep Getting Your
Benefits
You have only 10 days to ask us in writing to continue your benefits during your appeal. The 10 days start the day after you get this letter.
•
To continue benefits, complete our SSA-792 Statutory Benefit Continuation Election Statement form. Submit the form with your appeal request to your local Social Security office within 10 days. You can go to our website at https://www.ssa.gov/forms to locate this form. You can also contact us to request the form or if you need help filling out the form.
•
With this form, you can choose to continue or not continue getting benefits during your appeal. If applicable, you can also choose to continue only Medicare and for your family to keep getting their benefits if they are also receiving benefits on your record.
•
We must receive your appeal request with the SSA-792 form within 10 days to continue your benefits.
•
If you lose the appeal, you might have to pay back some or all of this money. If you are receiving Medicare, you will not have to pay back Medicare.
(UTI ALSC23)
You May Not Have to Pay Back the Money You Get During Your Appeal
(UTI ALS099)
If you ask us to continue your benefits during your appeal, and your appeal is not approved, we will start collecting the money you and your family received during your appeal. You can request to not pay the money back by asking for a waiver. We may approve your waiver if the overpayment was not your fault AND paying us back would mean that you cannot afford to meet your daily living expenses, or it would be unfair for some other reason. We may find you are not at fault for the overpayment of the benefits you received during your appeal if all the following are true:
•
You asked for an appeal because you believe you still have a disability.
•
You provided the requested evidence.
•
You attended all requested examinations.
Do
not
send the following caption and
paragraph
(4066) if the revision is due to a non-medical reason, such as
work.
How An Appeal Works
A Disability Hearing Officer (DHO) will decide (1) 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 (2) 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 (3) file before the meeting.
•
You can tell the DHO the reasons why you think (4) still disabled. You can give the DHO more facts and you can bring people to say why (5) disabled.
•
You can have the DHO ask people to come to the meeting to speak about (6) disability and bring important papers. You can question these people at the meeting.
•
You do not have to go to the meeting in person. If you do not want to go, you can give the DHO more facts you may have. The DHO will decide your case using these facts and what is now in your file. But if you go to the meeting, it may help the DHO decide your case.
Fill-ins
(1) your/his/her
(2) your/his/her
(3) your/his/her
(4) you are/he is/she is
(5) you are/he is/she is
(6) your/his/her
(UTI REPC01/REP002)
If You Want Help With Your Appeal
You may choose to have a representative help you with your case. We will work with this person just as we would work with you. If you decide to have a representative, you should find one quickly so that person can start preparing your case.
Many representatives charge a fee only if you win your case. Others may represent you for free. Generally, your representative cannot charge a fee unless we approve it. Your local Social Security office can give you a list of groups that can help you find a representative.
If you get a representative, you or that person must notify us in writing. You can go to https://secure.ssa.gov/ssa1696/front-end/ to complete the form with your representative online, download the form SSA-1696 "Claimant's Appointment of Representative" at www.ssa.gov/forms, or contact us to request a form.
You can also log into your
my Social Security account for information and online service options regarding your representation.
(UTI 4070)
If
(1)
Health Gets Worse
Fill-ins:
(1) Your/His/Her
If (1) health gets worse and you feel that (2) disabled again, please get in touch with us. (3) may be able to get benefits again.
Fill-ins:
(1)
your/claimant’s name (possessive)
(2)
you are/he is/she is
(3)
You/claimant’s name
(UTI CTDO)
Suspect Social Security Fraud?
Please visit https://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at (800) 269-0271. If you are a person who is deaf or hard of hearing, call TTY (866) 501-2101.
Need More
Help?
1.
Visit www.ssa.gov for fast, simple, and secure online services.
2.
Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.
3.
You may also call your local office at (1):
(2)
[Field Office Address
City, S tate ,
ZIP]
Fill-ins (per
DOORS):
(1) Local field office public line phone number
(2) Local field office address
If you contact us, please refer to this letter. It will help us answer your questions.
How Are We Doing? Go to www.ssa.gov/feedback to tell us.
Enclosure:
Explanation
If limited English proficiency (LEP) flag exists OR preferred language is not English
OR Unknown
Multi-language insert
NL 00705.206 Reopening Notice 2 – Allowance to Denial – Title XVI
Disability
Allowance to Denial
--
Title XVI
We are writing to you about (1) Supplemental Security Income (SSI) payments. We recently looked at (2) SSI claim again to make sure our decision was correct. After reviewing all of the information carefully, we are changing our decision. Based on our rules, we now find that (3) not disabled. Therefore, (4) claim is denied. You will get another letter soon about when (5) payments will stop.
Fill-ins:
(1)
your/claimant’s name (possessive)
(2)
your/his/her
(3)
you are/ he is/ she is
(4)
your/his/her
(5) your/ his/ her
The Decision
See the enclosed Explanation.
Attach
t
he
Personalized Disability Explanation (PDE)
language per DI 26530.020 and
DI 26530.055, including a list of the evidence, an explanation of what the evidence shows, and the
detailed ,
personalized reasons for the determination. For additional guidance, see Reopening of Prior
Determination DI 27536.015.
If concurrent claims are involved, include
the following
paragraph
:
This decision refers only to (1) Supplemental Security Income payments. You will get a separate letter about (2) Social Security Disability Insurance benefits.
Fill-ins:
(1)
your/claimant name (possessive)
(2)
your/his/her
(Universal
text identifier (UTI)
4054)
Who
Decided
(1)
Case
Fill-in:
(1)
Your/ his/
her
If DDS disability determination :
Doctors and other trained staff looked at this case and made this decision. They work for the State but used our rules.
If Federal disability determination :
Our doctors and other trained staff looked at this case and made this decision.
(UTI ALSC12)
If You Disagree With The Decision
(UTI ALS023 – modified to show the
SSA-789 instead of the SSA-561 . NOTE: If the revision
is due to a non-medical reason, such as work, show “SSA-561, called “Request for Reconsideration”
instead of the SSA-789. Do not include the language for the DHO hearing or statutory benefit
continuation.)
If you do not agree with this decision, you have the right to appeal. A person who did not make the first decision will decide the case. We will review the case and look at any new facts you have. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in your favor.
•
You have 60 days to ask for an appeal.
•
The 60 days start the day after you receive 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 period.
•
You must have a good reason if you wait more than 60 days to ask for an appeal.
•
You must ask for an appeal in writing. Please use our "Request for Reconsideration - Disability Cessation" form, SSA-789. You can go to our website at https://www.ssa.gov/forms to locate this form. You can also contact us to request the form or if you need help filling out the form.
Do not
send the following caption and paragraph 4061 if
there is a determination of fraud or similar fault, since FSF precludes the payment of statutory
benefit continuation.
Do not
send the following caption and paragraph if the
revision is due to a non-medical reason, such as work or other reason that precludes payment of
statutory benefit continuation
(SBC).
Instead,
include
Goldberg/Kelly payment continuation language in the decision notice as explained in
DI 27540.030.
(UTI
4059)
Appeal In 10 Days To Keep Getting Your
Benefits
You have only 10 days to ask us in writing to continue your benefits during your appeal. The 10 days start the day after you get this letter.
•
To continue benefits, complete our SSA-792 Statutory Benefit Continuation Election Statement form. Submit this form to your local Social Security office within 10 days. You can go to our website at https://www.sssa.gov/forms to locate this form. You can also contact us to request the form or if you need help filling out the form.
•
With this form, you can choose to continue or not continue getting benefits during your appeal. If applicable, you can also choose to continue only Medicare and for your family to keep getting their benefits if they are also receiving benefits on your record.
•
If you lose the appeal, you might have to pay back some or all of this money. If you are receiving Medicare, you will not have to pay back Medicare.
(UTI ALSC23)
You May Not
Have to Pay Back the Money You Get During Your Appeal
(UTI ALS099)
If you ask us to continue your benefits during your appeal, and your appeal is not approved, we will start collecting the money you and your family received during your appeal. You can request to not pay the money back by asking for a waiver. We may approve your waiver if the overpayment was not your fault AND paying us back would mean that you cannot afford to meet your daily living expenses, or it would be unfair for some other reason. We may find you are not at fault for the overpayment of the benefits you received during your appeal if all the following are true:
•
You asked for an appeal because you believe you still have a disability.
•
You provided the requested evidence.
•
You attended all requested examinations.
NOTE:
Do not
send the following caption and paragraph if the revision is due to a non-medical
reason, such as work .
(UTI 4066 )
How
An Appeal Works
A Disability Hearing Officer (DHO) will decide (1) 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 (2) 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 (3) file before the meeting.
•
You can tell the DHO the reasons you think (4) still disabled. You can give the DHO more facts and you can bring people to say why (5) disabled.
•
You can have the DHO ask people to come to the meeting to speak about (6) disability and bring important papers. You can question these people at the meeting.
•
You do not have to go to the meeting in person. If you do not want to go, you can give the DHO more facts you may have. The DHO will decide your case using these facts and what is now in the file. But, if you go to the meeting, it may help the DHO decide your case.
Fill-ins:
(1)
your/his/her
(2)
your/his/her
(3) your/his/her
(4) you are/he is/she is
(5) you are/he is /she is
(6) your/his/her
(UTI REPC01 )
If You Want Help With Your Appeal
(UTI REP002)
You may choose to have a representative help you with your case. We will work with this person just as we would work with you. If you decide to have a representative, you should find one quickly so that person can start preparing your case.
Many representatives charge a fee only if you win your case. Others may represent you for free. Generally, your representative cannot charge a fee unless we approve it. Your local Social Security office can give you a list of groups that can help you find a representative.
If you get a representative, you or that person must notify us in writing. You can go to https://secure.ssa.gov/ssa1696/front-end/
to complete the form with your representative online, download the form SSA-1696 "Claimant's Appointment of Representative" at www.ssa.gov/forms, or contact us to request a form.
You can also log into your my Social Security account for information and online service options regarding your representation.
(UTI 4070)
If
(1) Health
Gets Worse
Fill-ins:
(1) your/his/her
If (1) health gets worse and you feel that (2) disabled again, please get in touch with us. (3) may be able to get benefits again.
Fill-ins:
(1)
your/claimant’s name (possessive)
(2)
you are/he is/she is
(3)
You/claimant’s name
(UTI REF196)
Suspect Social Security Fraud?
Please visit https://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at (800) 269-0271. If you are deaf or hard of hearing, call TTY (866) 501-2101.
Need More
Help?
1.
Visit www.ssa.gov for fast, simple, and secure online service.
2.
Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.
3.
You may also call your local office at (1).
(2) [Field
Office Address
City, S tate ,
ZIP] per DOORS
Fill-ins (per DOORS)
(1) Local field office public line phone number
(2) Local field office address
How Are We Doing? Go to www.ssa.gov/feedback to tell us.
Enclosure:
Explanation
If Limited English Proficiency (LEP) flag exists OR Preferred Language is not English
or not Unknown:
Multi-lanuage insert
NL 00705.211 Reopening Notice 3 – Auxiliary – Title II
Use one of the following lead-in paragraphs:
Auxiliary
–
Lead
-
In
--
Allowance to Denial
We are writing to you about your Social Security benefits. We recently looked at (1) disability case again to make sure our decision was correct. After reviewing all of the information carefully, we are changing our decision. We now find that (2) is not disabled. Therefore, based on our rules, we are denying your claim for benefits. When (3) benefits stop, your benefits will also stop.
Fill-ins:
(1)
number holder’s name (possessive)
(2)
number holder's name
(3) number holder's name (possessive)
OR
Auxiliary
– Lead-In – Closed Period
We are writing to let you about your Social Security benefits. We recently looked at (1) disability case again to make sure our decision was correct. After reviewing all of the information carefully, we are changing our decision. We now find that (2) is no longer disabled. When (3) benefits stop, your benefits will also stop.
Fill-ins:
(1)
number holder’s name (possessive)
(2)
number holder's name
(3)
his/her
(Universal text identifier (UTI) ALSC12/ALS023)
If You Disagree With The Decision
If you do not agree with this decision, you have the right to appeal. A person who did not make the first decision will decide the case. We will review the case and look at any new facts you have. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in your favor.
•
You have 60 days to ask for an appeal.
•
The 60 days start the day after you receive 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 period.
•
You must have a good reason if you wait more than 60 days to ask for an appeal.
•
You must ask for an appeal in writing. Please use our “Request for Reconsideration” form, SSA-561. You can go to our website at www.ssa.gov/forms to locate this form. Or, you can submit your appeal request online at www.ssa.gov/disability/appeal. You can also contact us to request the form or if you need help filling out the form.
Do not
s end
the following caption and paragraph (4060) if there is a
determination of fraud or
similar
fault (FSF), since FSF precludes the payment of statutory benefit
continuation.
Do not
send the following caption and
paragraph if the revision is due to a non-medical reason, such as work, or other reason that
precludes statutory benefit continuation (SBC) payments (see DI
27540.025). However, a predetermination due process notice is needed.
(UTI 4060)
Appeal in
10 Day To
Keep Getting Your
Benefits
You have only 10 days to ask us in writing to continue your benefits during your appeal. The 10 days start the day after you get this letter.
•
To continue benefits, complete our SSA-792 Statutory Benefit Continuation Election Statement form. Submit the form with your appeal request to your local Social Security office within 10 days. You can go to our website at https://www.ssa.gov/forms to locate this form. You can also contact us to request the form or if you need help filling out the form.
•
Both you and (1) must ask for your payments to continue, and (2) must file an appeal within 10 days.
•
If (3) loses the appeal, you might have to pay back some or all of this money.
Fill-ins:
(1)
number holder’s name
(2)
he/she
(3) number holder's name
(UTI ALSC23/ALS099)
You May Not Have To Pay Back The Money You Get During Your Appeal
If you ask us to continue your benefits during your appeal, and your appeal is not approved, we will start collecting the money you and your family received during your appeal. You can request to not pay the money back by asking for a waiver. We may approve your waiver if the overpayment was not your fault AND paying us back would mean that you cannot afford to meet your daily living expenses, or it would be unfair for some other reason. We may find you are not at fault for the overpayment of the benefits you received during your appeal if all the following are true:
•
You asked for an appeal because you believe you still have a disability.
•
You provided the requested evidence.
•
You attended all requested examinations.
(UTI REPC01/REP002)
If You Want Help With Your Appeal
You may choose to have a representative help you with your case. We will work with this person just as we would work with you. If you decide to have a representative, you should find one quickly so that person can start preparing your case.
Many representatives charge a fee only if you win your case. Others may represent you for free. Generally, your representative cannot charge a fee unless we approve it. Your local Social Security office can give you a list of groups that can help you find a representative.
If you get a representative, you or that person must notify us in writing. You can go to https://secure.ssa.gov/ssa1696/front-end/ to complete the form with your representative online, download the form SSA-1696 "Claimant's Appointment of Representative" at www.ssa.gov/forms, or contact us to request a form.
You can also log into your mySocial Security account for information and online service options regarding your representation.
(UTI
CTDO)
Suspect
Social Security Fraud?
Please visit https://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at (800) 269-0271. If you are a person who is deaf or hard of hearing, call TTY (866) 501-2101.
Need More Help?
1. Visit www.ssa.gov for fast, simple, and secure online services.
2. Call us at 1-800-772-1213, weekdays from 8:00am to 7:00pm. If you are deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.
3. You may also call your local office at (1).
(2) [Field
Office Address
City, S tate ,
Zip
code]
Fill-ins (per DOORS):
(1) Local field office public line phone number
(2) Local field office address
If you contact us, please refer to this letter. It will help us answer your questions.
How Are We Doing? Go to www.ssa.gov/feedback to tell us.
Enclosure:
SSA Pub. No. 05-10058
NL 00705.216 Reopening Notice 4 – Allowance to Closed Period – Title II
Use one of the following lead-in paragraphs:
Lead-In
-
Reopening To Closed Period
-
Medical Improvement
We are writing to you about (1) Social Security Disability Insurance (SSDI) benefits. We recently looked at (2) claim again to make sure our decision was correct. After reviewing all of the information carefully, we are changing our decision. We now find that (3) disabled from (4) to (5). This means that (6) benefits will stop.
Fill-ins:
(1)
your/beneficiary’s name (possessive)
(2)
your/his/her
(3)
you were/he was/she was
(4)
Established onset date
(MM/DD/YYYY)
(5)
Closed period end date
(MM/DD/YYYY)
(6) your/his/her
OR
Lead-In
-
Reopening To Closed Period
-
Group I Exception
We are writing to you about (1) Social Security Disability Insurance (SSDI) benefits. We recently looked at (2) claim again to make sure our decision was correct. After reviewing all of the information carefully, we are changing that decision. Based on our rules, we have decided that (3) now able to work. This means that (4) benefits will stop.
Fill-ins:
(1)
your/beneficiary’s name (possessive)
(2) your/ his/ her
(3)
you are/he is/she is
(4)
your/his/her
OR
Lead-In
– Reopening to Closed Period – Group II Exception
We are writing to you about (1) Social Security Disability Insurance (SSDI) benefits. We recently looked at (2) claim again to make sure our decision was correct. After reviewing all of the information carefully, we are changing that decision. Based on our rules, we have decided that (3) no longer entitled to benefits.
Fill-ins:
(1)
your/beneficiary’s name (possessive)
(2) your/ his/ her
(3)
you are/he is/she is
The Decision
See the enclosed Explanation.
Attach
the
Personalized Disability
Explanation (PDE)
per DI
26530.020 and DI 26530.055, including a list of the evidence, an explanation of what the evidence
shows, and the detailed, personalized reasons for the determination. For additional guidance, see
Reopening of Prior Determination DI 27536.015.
If concurrent claims are involved, include
the following
paragraph :
This decision refers only to (1) Social Security Disability Insurance benefits. You will get a separate letter about (2) Supplemental Security Income payments.
Fill-ins:
(1)
your/beneficiary’s name (possessive)
(2)
your/his/her
(Universal
text identifier (UTI)
4054)
Who
Decided (1) Case
Fill-in:
(1)
Your/His/Her
If DDS disability determination :
Doctors and other trained staff looked at this case and made this decision. They work for the State but used our rules.
If Federal determination :
Our doctors and other trained staff looked at this case and made this decision.
(UTI ALS023 – modified to show the SSA-789 instead of the
SSA-561)
NOTE: If the revision is due to a non-medical reason, such as work, show
“SSA-561, called ‘Request for Reconsideration’” instead of the SSA-789. Do not include the language
for the DHO hearing or statutory benefit
continuation
(SBC).
If You Disagree With The Decision
If you do not agree with this decision, you have the right to appeal. A person who did not make the first decision will decide the case. We will review the case and look at any new facts you have. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in your favor.
•
You have 60 days to ask for an appeal.
•
The 60 days start the day after you receive 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 period.
•
You must have a good reason if you wait more than 60 days to ask for an appeal.
•
You must ask for an appeal in writing. Please use our "Request for Reconsideration - Disability Cessation" form, SSA-789. You can go to our website at https://www.ssa.gov/forms to locate this form. You can also contact us to request the form or if you need help filling out the form.
Do not
send the captions and paragraphs
UTIs 4059, ALSC23, and ALS099 if there is a determination of fraud or similar fault
(FSF) or if the revision is due to a non-medical reason. These types of revised determinations
preclude the payment of SBC. However, a predetermination due process notice is
needed, see DI 27505.015 and DI 27540.025).
(UTI 4059 modified to add fill-ins)
Appeal In 10 Days To Keep Getting Your
Benefits
You have only 10 days to ask us in writing to continue your benefits during your appeal. The 10 days start the day after you get this letter.
•
To continue benefits, complete our SSA-792 Statutory Benefit Continuation Election Statement form. Submit the form with your appeal request to your local Social Security office within 10 days. You can go to our website at https://www.ssa.gov/forms to locate this form. You can also contact us to request the form or if you need help filling out the form.
•
With this form, you can choose to continue or not continue getting benefits during your appeal. If applicable, you can also choose to continue only Medicare and for your family to keep getting their benefits if they are also receiving benefits on your record.
•
We must receive your appeal request with the SSA-792 form within 10 days to continue your benefits.
•
If you lose the appeal, you might have to pay back some or all of this money. If you are receiving Medicare, you will not have to pay back Medicare.
(UTI ALSC23)
You May Not Have to Pay Back the Money You Get During Your Appeal
(UTI ALS099)
If you ask us to continue your benefits during your appeal, and your appeal is not approved, we will start collecting the money you and your family received during your appeal. You can request to not pay the money back by asking for a waiver. We may approve your waiver if the overpayment was not your fault AND paying us back would mean that you cannot afford to meet your daily living expenses, or it would be unfair for some other reason. We may find you are not at fault for the overpayment of the benefits you received during your appeal if all the following are true:
•
You asked for an appeal because you believe you still have a disability.
•
You provided the requested evidence.
•
You attended all requested examinations.
Do not send the following caption and paragraph (UTI 4066) if the
revision is due to a non-medical reason, such as work.
How An Appeal Works
A Disability Hearing Officer (DHO) will decide (1) 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 (2) 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 (3) file before the meeting.
•
You can tell the DHO the reasons why you think (4) still disabled. You can give the DHO more facts and you can bring people to say why (5) disabled.
•
You can have the DHO ask people to come to the meeting to speak about (6) disability and bring important papers. You can question these people at the meeting.
•
You do not have to go to the meeting in person. If you do not want to go, you can give the DHO more facts you may have. The DHO will decide your case using these facts and what is now in your file. But if you go to the meeting, it may help the DHO decide your case.
Fill-ins
(1) your/his/her
(2) your/his/her
(3) your/his/her
(4)you are/he is/she is
(5) you are/he is/she is
(6) your/his/her
(UTI REPC01/REP002)
If You Want Help With Your Appeal
You may choose to have a representative help you with your case. We will work with this person just as we would work with you. If you decide to have a representative, you should find one quickly so that person can start preparing your case. Many representatives charge a fee only if you win your case. Others may represent you for free. Generally, your representative cannot chart a fee unless we approve it. Your local Social Security office can give you a list of groups that can help you find a representative.
If you get a representative, you or that person must notify us in writing. You can go to https://secure.ssa.gov/ssa1696/front-end/ to complete the form with your representative online, download the form SSA-1696 "Claimant's Appointment of Representative" at https://www.ssa.gov/forms, or contact us to request a form.
You can also log into your
my
SocialSecurity account for information and online service options regarding your representation.
(UTI 4070)
If
(1)
Health Gets Worse
Fill-ins:
(1) Your/His/Her
If (1) health gets worse and you feel that (2) disabled again, please get in touch with us. (3) may be able to get benefits again.
Fill-ins:
(1)
your/beneficiary’s name (possessive)
(2)
you are/he is/she is
(3)
You/beneficiary’s name
(UTI CTDO)
Suspect Social Security Fraud?
Please visit https://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at (800)269-0271. If you are a person who is deaf or hard of hearing, call TTY (866)501-2101.
Need More
Help?
1.
Visit www.ssa.gov for fast, simple, and secure online services.
2.
Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.
3.
You may also call your local office at (1).
(2) [Field
Office Address
City, S tate , ZIP]
Fill-ins (per DOORS):
(1) Local field office public line phone number
(2) Local field office address
If you contact us, please refer to this letter. It will help us answer your questions.
How Are We Doing? Go to www.ssa.gov/feedback to tell us.
If a determination of FSF is
not
involved, use:
Enclosure:
SSA Pub. No. 05-10090
If there is a determination of FSF, or if the revision is due to a non-medical reason,
use:
Enclosure:
SSA Pub. No. 05-10058
NL 00705.221 Reopening Notice 5 – Allowance to Closed Period – Title XVI
Use one of the following lead-in paragraphs:
Reopening To Closed Period - Medical Improvement - Title XVI
We are writing to you about (1) Supplemental Security Income payments. We recently looked at (2) claim again to see if our decision was correct. After reviewing all of the information carefully, we are changing our decision. We now find that (3) disabled from (4) to (5). This means that (6) payments will stop.
Fill-ins:
(1)
your/recipient’s name (possessive)
(2)
your/his/her
(3)
you were/recipient's
name
was
(4)
Established onset date
(MM/DD/YYYY)
(5)
Closed period end date
(MM/DD/YYYY)
(6)
your/his/her
OR
Reopening
To Closed Period - Group I Exception - Title XVI
We are writing to you about (1) Supplemental Security Income payments. We recently looked at (2) claim again to see if our decision was correct. After reviewing all of the information carefully, we are changing that decision. We have decided that (3) now able to work. This means that (4) payments will stop.
Fill-ins:
(1)
your/recipient’s name (possessive)
(2)
your/his/her
(3) you are/he is/she is
(4)
your/his/her
OR
Reopening
to Closed Period – Group II Exception – Title XVI
We are writing to you about (1) Supplemental Security Income payments. We recently looked at (2) claim again to see if our decision was correct. After reviewing all of the information carefully, we are changing that decision. Based on our rules, we have decided that (3) no longer eligible for payments.
Fill-ins:
(1)
your/recipient’s name (possessive)
(2)
your/his/her
(3) you are/he is/she is
The Decision
See the enclosed Explanation.
Attach
the Personalized Disability Explanation (PDE)
language per DI 26530.020 and
DI 26530.055, including a list of the evidence, an explanation of what the evidence shows, and the
detailed, personalized reasons for the determination. For additional guidance, see Reopening of
Prior Determination DI 27536.015.
If concurrent claims are involved, include
the following
paragraph :
This decision refers only to (1) Supplemental Security Income payments. You will get a separate letter about (2) Social Security Disability Insurance benefits.
Fill-ins:
(1)
your/recipient’s (possessive)
(2)
your/his/her
Who Decided (1) Case
Fill-in:
(1)
Your/His/Her
If DDS disability determination :
Doctors and other trained staff looked at this case and made this decision. They work for the State but used our rules.
If Federal disability determination :
Our doctors and other trained staff looked at this case and made this decision.
(Universal text identifiers (UTIs) ALSC12/ALS023 - modified to show SSA-789 instead of
SSA-561)
If You Disagree With The Decision
NOTE: If the revision is due to a non-medical reason, such as work, show
“SSA-561, called “Request for Reconsideration” instead of the SSA-789. Do not include the language
for the DHO hearing or statutory benefit continuation.
If you do not agree with this decision, you have the right to appeal. A person who did not make the first decision will decide the case. We will review the case and look at any new facts you have. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of the decision that you think are right. We will make a decision that may or may not be in your favor.
•
You have 60 days to ask for an appeal.
•
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 period.
•
You must have a good reason if you wait more than 60 days to ask for an appeal.
•
You must ask for an appeal in writing. Please use our "Request for Reconsideration - Disability Cessation -Right to Appear", form SSA-789. You may go to our website at https://www.ssa.gov/forms to locate the form. You can also contact us to request the form, or if you need help filling out the form.
If there is a determination of FSF, or if the revision is due to a non-medical reason,
use:
Do not
send the following caption and
paragraph 4061 if there is a determination of fraud or similar
fault , since FSF precludes the payment of statutory benefit
continuation.
Do not
send the following caption and paragraph if the
revision is due to a non-medical reason, such as work or other reason that precludes the payment of
SBC (see DI 27540.030).
Include Goldberg/Kelly payment continuation language in the decision
notice.
(UTI 4059)
Appeal In 10 Days To Keep Getting Your
Benefits
You have only 10 days to ask us in writing to continue your benefits during your appeal. The 10 days start the day after you get this letter.
•
To continue benefits, complete our SSA-792 Statutory Benefit Continuation Election Statement form. Submit the form with your appeal request to your local Social Security office within 10 days. You can go to our website at https://www.ssa.gov/forms to locate this form. You can also contact us to request the form or if you need help filling out the form.
•
With this form, you can choose to continue or not continue getting benefits during your appeal. If applicable, you can also choose to continue only Medicare and for your family to keep getting their benefits if they are also receiving benefits on your record.
•
We must receive your appeal request with the SSA-792 form within 10 days to continue your benefits.
•
If you lose the appeal, you might have to pay back some or all of this money. If you are receiving Medicare, you will not have to pay back Medicare.
(UTIs ALSC23/ALS099)
You May Not
Have to Pay Back The Money You Get During Your Appeal
If you ask us to continue your benefits during your appeal, and your appeal is not approved, we will start collecting the money you and your family received during your appeal. You can request to not pay the money back by asking for a waiver. We may approve your waiver if the overpayment was not your fault AND paying us back would mean that you cannot afford to meet your daily living expenses, or it would be unfair for some other reason. We may find you are not at fault for the overpayment of the benefits you received during your appeal if all the following are true:
•
You asked for an appeal because you believe you still have a disability.
•
You provided the requested evidence.
•
You attended all requested examinations.
Do not
send the following caption and paragraph if the
revision is due to a non-medical reason, such as work.
How An Appeal Works
A Disability Hearing Officer (DHO) will decide your 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 your appeal. The meeting works like this:
•
The DHO will write you about the time and place for the meeting.
•
You can look at your file before the meeting.
•
You can tell the DHO why you think you are still (1). You can give the DHO more facts and you can bring people to say why you are (2).
•
You can have the DHO ask people to come to the meeting and bring important papers. You can question these people at the meeting.
•
You do not have to go to the meeting in person. If you do not want to go, you can give the DHO more facts you may have. The DHO will decide your case using these facts and what is now in your file. But, if you go to the meeting, it may help the DHO decide your case.
Fill-ins:
(1)
disabled/blind
(2)
disabled/blind
If You Want Help With Your Appeal
You may choose to have a representative help you with your case. We will work with this person just as we would work with you. If you decide to have a representative, you should find one quickly so that person can start preparing your case.
Many representatives charge a fee only if you win your case. Others may represent you for free. Generally, your representative cannot charge a fee unless we approve it. Your local Social Security office can give you a list of groups that can help you find a representative. If you get a representative, you or that person must notify us in writing. You can go to https://secure.ssa.gov/ssa1696/front-end/ to complete the form with your representative online, download the form SSA-1694 "Claimant's Appointment of Representative" at www.ssa.gov/forms, or contact us to request a form. You can also log into your mySocialSecurity account for information and online service options regarding your representation.
(UTI 4070)
If You r Health Gets Worse
If (1) health gets worse and you feel that (2) disabled again, please get in touch with us. (3) may be able to get payments again.
Fill-ins:
(1)
your/recipient’s name (possessive)
(2)
you are/he is/she is
(3)
You/recipient’s name
(UTI CTDO)
Suspect Social Security Fraud?
Please visit https://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at (800) 269-0271. If you are deaf or hard of hearing, call TTY (866) 501-2101.
Need More Help?
•
Visit www.ssa.gov for fast, simple, and secure online service.
•
Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.
•
You may also call your local office at (1).
(2) [Field Office Address
City, S tate , ZIP]
Fill-ins:
(1) Local field office public line phone number
(2) Local field office address
If you contact us, please refer to this letter. It will help us answer your questions.
How are we
doing? Go to www.ssa.gov/feedback to tell us.
If a determination of FSF is
not
involved, use:
Enclosure:
SSA Pub. No. 05-10090