For purposes of the notice, you may use the following sample language as a model for additional language to include in the notice, with fill-ins based on the facts in the situation:
“We are writing to tell you that we have approved the revised fee agreement between you and your representative, dated [date of revised fee agreement]. Earlier, we told you that your representative could charge you $[total amount previously authorized]. Based on the revised fee agreement, your representative can charge you $[total amount calculated under the revised fee agreement]. This is instead of, not in addition to, the fee we approved earlier. [Your/your family’s] past-due benefits used to decide the amount of the fee were $[total amount of past-due benefits].”
“The amount of the approved fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors’ or hospitals’ reports). This is a matter between you and your representative.”
[Use this paragraph if the representative received direct payment of a fee from Title II or Title XVI past-due benefits.]
“Earlier, we paid your representative $ [total amount actually paid to representative from withheld past-due benefits AFTER subtracting the user fee] from your past-due benefits. This amount is the fee we approved before, less a service charge.”
“After we paid your representative, we paid you the rest of the amount we withheld from your benefits. Therefore, you and your representative must decide how to settle the additional $[total amount calculated under the revised fee agreement MINUS total amount previously authorized BEFORE subtracting the user fee] you owe. We are sending a copy of this letter to your representative.”
NOTE: If an additional fee amount is authorized based on past-due benefits and a representative who may receive direct payment later contacts SSA indicating that he or she has been unable to collect the additional amount authorized, follow the procedures in GN 03920.055C.