TN 4 (01-97)

DI 90070.900 DAA (P.L. 104-121) Exhibits

EXHIBIT 1 “WAYS TO APPEAL” - SSI

HOW TO APPEAL YOUR SUPPLEMENTAL SECURITY INCOME (SSI) DISABILITY DECISION UNDER P.L. 104-121

 

There are different ways to appeal. The person who gave you this form can tell how these appeals work. You can have a lawyer, friend, or someone else help you with your appeal.

Here are different ways to appeal:

1. 1. 

   CASE REVIEW

You can give us more facts to add to your file. Then we'll decide your case again. You don't meet with the person who decides your case.

1. 2. 

   FACE-TO-FACE DUE PROCESS EVIDENTIARY HEARING

You'll meet with the person who will decide your case. You can tell that person why you think you're right. You can give us more facts to help prove you're right. You can bring other people to help explain your case.

Plus, we can make people come to your meeting to help prove you're right. We can do this even if they don't want to help you. You can question these people at your meeting.

Now you know the two kinds of appeals. We'll help you fill out your appeal request.

There are groups that can help you with your appeal. Some can give you free help with your appeal. We can give you the names of these groups.

EXHIBIT 2 Concurrent TII, T16 - DENIAL OF INITIAL DISABILITY CLAIM - DAA IS MATERIAL -- (Patterned on SSA-L442)

Language:

We are writing about   (1)   claims for Social Security and Supplemental Security Income (SSI) disability benefits. Based on a review of   (2)   health problems,   (3)   not qualify for benefits on either claim. The law says we cannot pay disability benefits based on   (4)   . Because   (5)   health problems are based on   (6)   , we cannot pay   (7)   any benefits.

 

Fill-ins:

1. 1. 

   your/[Claimant name, possessive]

2. 2. 

   your/his/her

3. 3. 

   you do/he does/she does

4. 4. 

   drug addiction/alcoholism/drug addiction and alcoholism

5. 5. 

   your/his/her

6. 6. 

   drug addiction/alcoholism/drug addiction and alcoholism

7. 7. 

   you/him/her

    

The Decision on   (1)   Case

 

Fill-ins:

1. 1. 

   Your/[Claimant name, possessive][ Personalized Denial Language ]

About the Decision

Choice 1: Notice prepared by State DDS:

Doctors and other trained staff looked at this case and made the decision that   (1)   health problems are based on   (2)   . They work for the state but used our rules.

Please remember that there are many types of disability programs, both government and private, which use different rules. A person may be receiving benefits under another program and still not be entitled under our rules. This may be true in this case.

 

Fill-ins:

1. 1. 

   your/his/her

2. 2. 

   drug addiction/alcoholism/drug addiction and alcoholism

    

Choice 2: Notice prepared by FDDS:

Our doctors and other trained staff looked at this case and made the decision that   (1)   health problems are based on   (2)   .

Please remember that there are many types of disability programs, both government and private, which use different rules. A person may be receiving benefits under another program and still not be entitled under our rules. This may be true in this case.

 

Fill-in:

1. 1. 

   your/his/her

2. 2. 

   drug addiction/alcoholism/drug addiction and alcoholism

    

Other Benefits

Based on the applications   (1)   filed   (2)      (3)   not entitled to any other benefits besides those   (4)   may already be getting. In the future, if   (5)     (6)     (7)   may be entitled to benefits,   (8)   will need to file again.

 

Fill-ins:

1. 1. 

   you/she/he

2. 2. 

   you/Claimant name

3. 3. 

   are/is

4. 4. 

   you/she/he

5. 5. 

   you/she/he

6. 6. 

   think/thinks

7. 7. 

   you/she/he

8. 8. 

   you/she/he

    

If You Disagree With The Decision

If you disagree with the decision that   (1)   health problems are based on   (2)  , you have the right to appeal. We will review your case and consider any new facts you have. A person who did not make the first decisions will decide your case.

• •

  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 for waiting more than 60 days to ask for an appeal.

• •

  You have to ask for an appeal in writing. We will ask you to sign a form SSA-561-U2, called “Request for Reconsideration.” Contact one of our offices if you want help.

Please read the enclosed pamphlets, “Your Right to Question The Decision Made On Your Social Security Claim” and “Your Right to Question the Decision Made on Your SSI Claim.” They contain more information about appeals.

 

Fill-ins:

1. 1. 

   your/[Claimant name, possessive]

2. 2. 

   drug addiction/alcoholism/drug addiction and alcoholism

    

New Application

You have the right to file a new application at any time, but filing a new application is not the same as appealing a decision. If you disagree with either of these decisions and you file a new application for Social Security or SSI instead of appealing,   (1)   might lose some benefits, or not qualify for any benefits. Also, we could deny the new Social Security application using this decision, if the facts and issues are the same. So, if you disagree with either decision, you should ask for an appeal within 60 days.

 

Fill-in:

1. 1. 

   you/[Claimant name]

    

If You Want Help With Your Appeal

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 you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a lawyer, we will withhold up to 25 percent of any past due Social Security benefits to pay toward the fee. We do not withhold money from SSI benefits to pay your lawyer.

 

Information About Medicaid   (1)  

  (2)  

  (3)  

 

Fill-ins:

1. 1. 

   Choice 1: And Other Benefits
   Choice 2: NULL

2. 2. 

   Choice 1: Paragraph 1150 from NL 00804.110
   Choice 2: Paragraph 1151 from NL 00804.110
   Choice 3: Paragraph 1155 from NL 00804.110
   Choice 4: Paragraph 1170 from NL 00804.110

3. 3. 

   Choice 1: Paragraph 1311 from NL 00804.190
   Choice 2: NULL

    

OPTIONAL PARAGRAPH:

Family Benefits

If   (1)   a spouse or child we cannot pay them benefits unless   (2)   entitled to Social Security benefits.

 

Fill-ins:

1. 1. 

   you have/[claimant name]has

2. 2. 

   you are/he is/she is

    

If You Have Any Questions

If you have any questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at[FO phone number] . We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

[Field Office Address
City, ST, ZIP]

If you do call or visit an office, please have this letter with you. It will help us answer your questions.

[Name]
Regional Commissioner

Enclosures:

SSA Pub. No. 05-10058

SSA Pub. No. 05-11008

EXHIBIT 3 DENIAL OF INITIAL DISABILITY CLAIM - DAA IS MATERIAL - TITLE II (Patterned on SSA-L443)

 

Language:

We are writing about   (1)   claim for Social Security disability benefits. Based on a review of   (2)   health problems,   (3)    not qualify for benefits on this claim. The law says we cannot pay disability benefits based on   (4)   . Because   (5)   health problems are based on   (6)   , we cannot pay   (7)   any benefits.

 

Fill-ins:

1. 1. 

   your/[Claimant name, possessive]

2. 2. 

   your/his/her

3. 3. 

   you do/he does/she does

4. 4. 

   drug addiction/alcoholism/drug addiction and alcoholism

5. 5. 

   your/his/her

6. 6. 

   drug addiction/alcoholism/drug addiction and alcoholism

7. 7. 

   you/him/her

    

The Decision on   (1)   Case

 

Fill-in:

1. 1. 

   Your/[Claimant name, possessive]

[ Personalized Denial Language]

SEE NOTE IN CONCURRENT NOTICE

 

About the Decision

 

Choice 1: Notice prepared by State DDS:

Doctors and other trained staff looked at this case and made the decision that   (1)   health problems are based on   (2)   . They work for the state but used our rules.

Please remember that there are many types of disability programs, both government and private, which use different rules. A person may be receiving benefits under another program and still not be entitled under our rules. This may be true in this case.

 

Fill-ins:

1. 1. 

   your/his/her

2. 2. 

   drug addiction/alcoholism/drug addiction and alcoholism

    

Choice 2: Notice prepared by FDDS:

Our doctors and other trained staff looked at this case and made the decision that   (1)   health problems are based on   (2)   .

Please remember that there are many types of disability programs, both government and private, which use different rules. A person may be receiving benefits under another program and still not be entitled under our rules. This may be true in this case.

 

Fill-ins:

1. 1. 

   your/his/her

2. 2. 

   drug addiction/alcoholism/drug addiction and alcoholism

    

Other Benefits

Based on the applications   (1)   filed,   (2)      (3)   not entitled to any other benefits besides those   (4)   may already be getting. In the future, if   (5)     (6)     (7)   may be entitled to benefits,   (8)   will need to file again.

 

Fill-ins:

1. 1. 

   you/she/he

2. 2. 

   you/Claimant name

3. 3. 

   are/is

4. 4. 

   you/she/he

5. 5. 

   you/she/he

6. 6. 

   think/thinks

7. 7. 

   you/she/he

8. 8. 

   you/she/he

    

If You Disagree With The Decision

If you disagree with the decision that   (1)   health problems are based on   (2)  , you have the right to appeal. We will review your case and consider any new facts you have. A person who did not make the first decisions will decide your case.

• •

  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 for waiting more than 60 days to ask for an appeal.

• •

  You have to ask for an appeal in writing. We will ask you to sign a form SSA-561-U2, called “Request for Reconsideration.” Contact one of our offices if you want help.

Please read the enclosed pamphlet, “Your Right to Question the Decision Made on Your Social Security Claim.” It contains more information about the appeal.

 

Fill-ins:

1. 1. 

   your/[Claimant name, possessive]

2. 2. 

   drug addiction/alcoholism/drug addiction and alcoholism

    

New Application

You have the right to file a new application at any time, but filing a new application is not the same as appealing this decision. If you disagree with this decision and you file a new application instead of appealing:

• •

    (1)   might lose some benefits, or not qualify for any benefits, and

• •

  we could deny the new application using this decision, if the facts and issues are the same.

So, if you disagree with this decision, you should ask for an appeal within 60 days.

 

Fill-in:

1. 1. 

   you/[Claimant name]

If You Want Help With Your Appeal

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 you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a lawyer, we will withhold up to 25 percent of any past due Social Security benefits to pay toward the fee.

 

OPTIONAL PARAGRAPH:

Family Benefits

If   (1)   a spouse or child we cannot pay them benefits unless   (2)   entitled to Social Security benefits.

 

Fill-ins:

1. 1. 

   you have/[claimant name]has

2. 2. 

   you are/he is/she is

    

If You Have Any Questions

If you have any questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at[FO phone number] . We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

 

[Field Office Address
City, ST, ZIP]

If you do call or visit an office, please have this letter with you. It will help us answer your questions.

 

[Name]
Regional Commissioner

 

Enclosure:

 

SSA Pub. No. 05-10058

EXHIBIT 4 DENIAL OF INITIAL DISABILITY CLAIM - DAA IS MATERIAL - TITLE XVI (Patterned on SSA-L444)

 

Language:

We are writing about   (1)   claim for Supplemental Security Income (SSI) payments. Based on a review of   (2)   health problems,   (3)   not qualify for benefits on this claim. The law says we cannot pay SSI disability benefits based on   (4)   . Because   (5)   health problems are based on   (6)   , we cannot pay    (7)   any benefits.

 

Fill-ins:

1. 1. 

   your/[Claimant name, possessive]

2. 2. 

   your/his/her

3. 3. 

   you do/he does/she does

4. 4. 

   drug addiction/alcoholism/drug addiction and alcoholism

5. 5. 

   your/his/her

6. 6. 

   drug addiction/alcoholism/drug addiction and alcoholism

7. 7. 

   you/him/her

    

The Decision on   (1)   Case

 

Fill-in:

1. 1. 

   Your/[Claimant name, possessive]

[Personalized Denial Language]

SEE NOTE IN CONCURRENT NOTICE

 

About the Decision

Choice 1: Notice prepared by State DDS:

Doctors and other trained staff looked at this case and made the decision that   (1)   health problems are based on   (2)   . They work for the state but used our rules.

Please remember that there are many types of disability programs, both government and private, which use different rules. A person may be receiving benefits under another program and still not be entitled under our rules. This may be true in this case.

 

Fill-ins:

1. 1. 

   your/his/her

2. 2. 

   drug addiction/alcoholism/drug addiction and alcoholism

    

Choice 2: Notice prepared by FDDS:

Our doctors and other trained staff looked at this case and made the decision that   (1)   health problems are based on   (2)   .

Please remember that there are many types of disability programs, both government and private, which use different rules. A person may be receiving benefits under another program and still not be entitled under our rules. This may be true in this case.

 

Fill-ins:

1. 1. 

   your/his/her

2. 2. 

   drug addiction/alcoholism/drug addiction and alcoholism

    

OPTIONAL PARAGRAPH:

The following paragraph will be used when the field office takes an SSI application and determines the individual is not entitled to any or additional title II benefits. As a result the FO does not take a supplemental title II application, but instead alerts the DDS to use this paragraph. It is patterned after paragraph 1598. That paragraph cannot be used in this letter as it stresses that case review is the only appeal available for title II. As this is also true for title XVI in these cases, the emphasis is unnecessary and confusing.

 

Information about Social Security Benefits

The application you filed for SSI was also a claim for Social Security benefits. We looked into this, and decided   (1)   can't get any Social Security benefits   (2)   . If you disagree with this decision, you have the right to appeal. The appeal is described in this letter.

 

Fill-ins:

1. 1. 

   you/[Claimant name]

2. 2. 

   except the benefit you are already getting/except the benefit she is already getting/except the benefit he is already getting/Null

    

If You Disagree With The Decision

If you disagree with the decision that   (1)   health problems are based on   (2)   , you have the right to appeal. We will review your case and consider any new facts you have. A person who did not make the first decisions will decide your case.

• •

  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 for waiting more than 60 days to ask for an appeal.

• •

  You have to ask for an appeal in writing. We will ask you to sign a form SSA-561-U2, called “Request for Reconsideration.” Contact one of our offices if you want help.

Please read the enclosed pamphlet, “Your Right to Question the Decision Made on Your SSI Claim.” It contains more information about the appeal.

 

Fill-ins:

1. 1. 

   your/[Claimant name, possessive]

2. 2. 

   drug addiction/alcoholism/drug addiction and alcoholism

    

How the Appeal Works

You have the right to review the facts in your case. You can give us more facts to add to your file. Then we will decide your case again. You will not meet the person who will decide your case.

 

New Application

You have the right to file a new application at any time, but filing a new application is not the same as appealing this decision. If you disagree with this decision and you file a new application instead of appealing,   (1)    might lose some benefits, or not qualify for any benefits. So, if you disagree with this decision, you should ask for an appeal within 60 days.

 

Fill-in:

1. 1. 

   you/[Claimant name]

    

If You Want Help With Your Appeal

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 you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it.

 

Information About Medicaid   (1)  

  (2)  

  (3)  

 

Fill-ins:

1. 1. 

   Choice 1 - And Other Benefits
   Choice 2 - NULL

2. 2. 

   Choice 1 - Paragraph 1150 from NL 00804.110
   Choice 2 -Paragraph 1151 from NL 00804.110
   Choice 3 - Paragraph 1155 from NL 00804.110
   Choice 4 - Paragraph 1170 from NL 00804.110

3. 3. 

   Choice 1 - Paragraph 1311 from NL 00804.190
   Choice 2 -NULL

    

If You Have Any Questions

If you have any questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at[FO phone number] . We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

 

[Field Office Address
City, ST, ZIP]

If you do call or visit an office, please have this letter with you. It will help us answer your questions.

 

[Name]
Regional Commissioner

 

Enclosure:

SSA Pub. No. 05-11008

EXHIBIT 5 DECISION PARAGRAPH FOR PDN - DENIAL - DAA IS MATERIAL

 

We reviewed the facts in   (1)   case and decided that   (2)   a contributing factor material to a finding of disability. This means   (3)   would not be disabled if   (4)   stopped using   (5)   . Therefore we cannot consider   (6)   disabled under the law.

 

Fill-ins:

1. 1. 

   your/his/her

2. 2. 

   drug addiction is/alcoholism is/drug addiction and alcoholism are

3. 3. 

   you/he/she

4. 4. 

   you/he/she

5. 5. 

   drugs/alcohol/drugs and alcohol

6. 6. 

   you/him/her

EXHIBIT 6 SAMPLE NOTICE - Title XVI DENIAL - DAA IS MATERIAL (Not according to Notice Standards)

 

Social Security Administration

Supplemental Security Income

Notice of Disapproved Claim

 

Date: May 22, 1996
Claim Number: 123-45-6789D

 

Addressee Name

Street Address

City, St 00000

 

We are writing about your claim for Supplemental Security Income (SSI) payments. Based on a review of your health problems, you do not qualify for benefits on this claim. The law says we cannot pay SSI disability benefits based on drug addiction. Because drug addiction is a contributing factor material to your disability, we cannot pay you any benefits.

 

The Decision on Your Case

We used the following reports to decide your case.

Medical records from Creek Medical Center for December 23, l995 through March 4, l996;
Dr. John N. Nee's report dated March 28, l996; and
Dr. Jack C. Lemon's report dated April 7, l996.

We reviewed the facts in your case and decided that drug addiction is a contributing factor material to a finding of disability. This means you would not be disabled if you stopped using drugs. Therefore, we cannot consider you disabled under the law.

You said that you are unable to work because (dictated text)xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxx.

The medical information shows(dictated text) xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.

Enclosure:

SSA Pub. No. 05-11008

See Next Page

123-00-6789D
Page 2 of 4

 

About the Decision

Doctors and other trained staff looked at this case and made the decision that your health problems are based on drug addiction. They work for the state but used our rules.

Please remember that there are many types of disability programs, both government and private, which use different rules. A person may be receiving benefits under another program and still not be entitled under our rules. This may be true in this case.

 

Information About Social Security Benefits

The application you filed for SSI was also a claim for Social Security benefits. We looked into this, and decided you can't get any Social Security benefits. If you disagree with this decision, you have the right to appeal. The appeal is described in this letter.

 

If You Disagree With The Decision

If you disagree with the decision that your health problems are based on drug addiction, you have the right to appeal. We will review your case and consider any new facts you have. A person who did not make the first decision will decide your case.

• •

  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 for waiting more than 60 days to ask for an appeal.

• •

  You have to ask for an appeal in writing. We will ask you to sign a form SSA-561-U2, called “Request for Reconsideration.” Contact one of our offices if you want help.

Please read the enclosed pamphlet, “Your Right to Question the Decision Made on Your SSI Claim.” It contains more information about the appeal.

123-45-6789DI
Page 3 of 4

 

How the Appeal Works

You have the right to review the facts in your case. You can give us more facts to add to your file. Then we will decide your case again. You will not meet the person who will decide your case.

 

New Application

You have the right to file a new application at any time, but filing a new application is not the same as appealing this decision. If you disagree with this decision and you file a new application instead of appealing, you might lose some benefits, or not qualify for any benefits. So, if you disagree with this decision, you should ask for an appeal within 60 days.

 

If You Want Help With Your Appeal

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 you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it.

 

Information About Medicaid

Since you are not receiving SSI payments, you cannot get Medicaid based on SSI. Usually, people who live in Texas get Medicaid only if they receive SSI payments or Aid to Families with Dependent Children. However, Texas does offer Medicaid to others, such as:

• •

  children with low incomes,

• •

  women who are pregnant,

• •

  people in nursing homes, and

• •

  people who have Medicare Part A and meet certain income and resource rules.

Please contact the Texas Department of Human Services if you have any questions about their Medicaid program.

123-45-6789DI
Page 4 of 4

 

If You Have Any Questions

If you have any questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-333-123-4567. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

 

123 Elm Street
Oak, TX 12345

 

If you do call or visit an office, please have this letter with you. It will help us answer your questions.

 

 

[Name]
Regional Commissioner

EXHIBIT 7 Reconsideration Disability Denial - DAA is Material - Concurrent Title II - Title XVI

Language:

You asked us to take another look at   (1)   claims for Social Security and Supplemental Security Income (SSI) disability benefits. Someone who did not make the first decision reviewed   (2)   case, including any new facts we received. Based on this review, we found that our first decision was correct. The law says we cannot pay disability benefits based on   (3)   . Because   (4)   health problems are based on   (5)   , we cannot pay   (6)   any benefits.

 

Fill-ins:

1. 1. 

   your/[Claimant name, possessive]

2. 2. 

   your/[Claimant name, possessive]

3. 3. 

   drug addiction/alcoholism/drug addiction and alcoholism

4. 4. 

   your/his/her

5. 5. 

   drug addiction/alcoholism/drug addiction and alcoholism

6. 6. 

   you/him/her

    

The Decisions on   (1)   Case

 

  (2)  

 

Fill-ins:

1. 1. 

   Your/[Claimant name, possessive]

2. 2. 

   [Personalized Denial Language]

   [Including decision paragraph: Exhibit 1D (cleared for initial disability denials)]

We reviewed the facts in   (1)   case and decided that   (2)   a contributing factor material to a finding of disability. This means   (3)   would not be disabled if   (4)   stopped using   (5)   . Therefore, we cannot consider   (6)   disabled under the law.

 

Fill-ins:

1. 1. 

   your/his/her

2. 2. 

   drug addiction is/alcoholism is/drug addiction and alcoholism are

3. 3. 

   you/he/she

4. 4. 

   you/he/she

5. 5. 

   drugs/alcohol/drugs and alcohol

6. 6. 

   you/him/her

    

About the Decisions

Please remember that there are many types of disability programs, both government and private, which use different rules. A person may be receiving benefits under another program and still not be entitled under our rules. This may be true in this case.

 

Information About Medicaid   (1)  

 

Fill-ins:

1. 1. 

   And Other Benefits/NULL

    

OPTIONAL PARAGRAPH:

MDC010 is an optional paragraph. While it will be used in most cases, it is possible that another claim could be unadjudicated when the decisions have been made on the title II and title XVI disability claims.

 

Based on the applications   (1)   filed,   (2)      (3)   not entitled to any other Social Security or SSI benefits besides those   (4)   may already be getting. In the future, if   (5)      (6)     (7)   may be entitled to benefits,   (8)   will need to file again.

  (9)  

  (10)  

 

Fill-ins:

1. 1. 

   you/she/he

2. 2. 

   you/Claimant name

3. 3. 

   are/is

4. 4. 

   you/she/he

5. 5. 

   you/she/he

6. 6. 

   think/thinks

7. 7. 

   you/she/he

8. 8. 

   you/she/he

9. 9. 

   Choice 1: MDC012: (Paragraph 1150 from NL 00804.110)
   Choice 2: MDC013: (Paragraph 1151 from NL 00804.110)
   Choice 3: MDC014: (Paragraph 1155 from NL 00804.110)
   Choice 4: MDC016: (Paragraph 1170 from NL 00804.110)

10. 10. 

    Choice 1: SAS001: (Paragraph 1311 from NL 00804.190)
    Choice 2: NULL

     

If You Disagree With The Decisions

If you disagree with the decision that   (1)   health problems are based on   (2)   , you have the right to request a hearing. A person who has not seen your case before will look at it. That person is an Administrative Law Judge (ALJ). The ALJ will review your case again and consider any new facts you have before deciding your case.

• •

  You have 60 days to ask for a hearing.

• •

  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 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 a hearing.

• •

  You have to ask for a hearing in writing. We will ask you to sign a form HA-501-U5, called “Request for Hearing.” Contact one of our offices if you want help.

   

Fill-ins:

1. 1. 

   your/his/her

2. 2. 

   drug addiction/alcoholism/drug addiction and alcoholism

    

How The Hearing Process Works

The ALJ will mail you a letter at least 20 days before the hearing to tell you its date, time and place. The letter will explain the law in your case and tell you what has to be decided. Since the ALJ will review all the facts in your case, it is important that you give us any new facts as soon as you can.

The hearing is your chance to tell the ALJ why you disagree with the decisions in your case. You can give the ALJ new evidence and bring people to testify for you. The ALJ also can require people to bring important papers to your hearing and give facts about your case. You can question these people at your hearing.

Please read the enclosed pamphlet “Your Right To An Administrative Law Judge Hearing And Appeals Council Review Of Your Social Security Case.” It has more information about the hearing.

 

It Is Important To Go To The Hearing

It is very important that you go to the hearing. If for any reason you can't go, contact the ALJ as soon as possible before the hearing and explain why. The ALJ will reschedule the hearing if you have a good reason.

If you don't go to the hearing and don't have a good reason for not going, the ALJ may dismiss your request for a hearing.

 

New Application

You have the right to file a new application at any time, but filing a new application is not the same as appealing a decision. If you disagree with either of these decisions and you file a new application for Social Security or SSI instead of appealing,   (1)   might lose some benefits, or not qualify for any benefits. Also, we could deny the new Social Security application using this decision, if the facts and issues are the same. So, if you disagree with either decision, you should ask for an appeal within 60 days.

 

Fill-in:

1. 1. 

   you/[Claimant name]

    

If You Want Help With Your Hearing

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 you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a lawyer, we will withhold up to 25 percent of any past due Social Security benefits to pay toward the fee. We do not withhold money from SSI benefits to pay your lawyer.

 

If You Have Any Questions

If you have any questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at[FO phone number] . We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

 

[Field Office Address
City, ST, ZIP]

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

 

[Name]
Regional Commissioner

 

[Show at bottom of first page of notice]

Enclosure:

SSA Pub. No. 70-10281

EXHIBIT 8 Reconsideration Disability Denial - DAA Is Material - Title II

 

Language:

 

You asked us to take another look at   (1)   claim for Social Security disability benefits. Someone who did not make the first decision reviewed   (2)   case, including any new facts we received. Based on this review, we found that our first decision was correct. The law says we cannot pay disability benefits based on   (3)   . Because    (4)   health problems are based on   (5)   , we cannot pay   (6)   any benefits.

 

Fill-ins:

1. 1. 

   your/[Claimant name, possessive]

2. 2. 

   your/[Claimant name, possessive]

3. 3. 

   drug addiction/alcoholism/drug addiction and alcoholism

4. 4. 

   your/his/her

5. 5. 

   drug addiction/alcoholism/drug addiction and alcoholism

6. 6. 

   you/him/her

    

The Decision on   (1)   Case

 

  (2)  

 

Fill-ins:

1. 1. 

   Your/[Claimant name, possessive]

2. 2. 

   [Personalized Denial Language][Including decision paragraph: (cleared for initial disability denials) -See Concurrent Notice, above]

    

About the Decision

Please remember that there are many types of disability programs, both government and private, which use different rules. A person may be receiving benefits under another program and still not be entitled under our rules. This may be true in this case.

 

OPTIONAL PARAGRAPH:

This is an optional paragraph. While it will be used in most cases, it is possible that another claim could be unadjudicated when the decision has been made on the title II disability claim.

 

Other Benefits

 

Based on the application   (1)   filed,   (2)      (3)   not entitled to any other Social Security benefits besides those   (4)   may already be getting. In the future, if   (5)     (6)     (7)   may be entitled to benefits,   (8)    will need to file again.

 

Fill-ins:

1. 1. 

   you/she/he

2. 2. 

   you/Claimant name

3. 3. 

   are/is

4. 4. 

   you/she/he

5. 5. 

   you/she/he

6. 6. 

   think/thinks

7. 7. 

   you/she/he

8. 8. 

   you/she/he

    

If You Disagree With The Decision

If you disagree with the decision that   (1)   health problems are based on   (2)   , you have the right to request a hearing. A person who has not seen your case before will look at it. That person is an Administrative Law Judge (ALJ). The ALJ will review your case again and consider any new facts you have before deciding your case.

• •

  You have 60 days to ask for a hearing.

• •

  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 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 a hearing.

• •

  You have to ask for a hearing in writing. We will ask you to sign a form HA-501-U5, called “Request for Hearing.” Contact one of our offices if you want help.

Please read the enclosed pamphlet, “Your Right to An Administrative Law Judge Hearing and Appeals Council Review of Your Social Security Case.” It contains more information about the hearing.

 

Fill-ins:

1. 1. 

   your/his/her

2. 2. 

   drug addiction/alcoholism/drug addiction and alcoholism

    

New Application

You have the right to file a new application at any time, but filing a new application is not the same as appealing this decision. If you disagree with this decision and you file a new application instead of appealing:

• •

    (1)   might lose some benefits, or not qualify for any benefits, and

• •

  we could deny the new application using this decision, if the facts and issues are the same.

So, if you disagree with this decision, you should ask for an appeal within 60 days.

 

Fill-in:

1. 1. 

   you/[Claimant name]

    

If You Want Help With Your Hearing

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 you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a lawyer, we will withhold up to 25 percent of any past due Social Security benefits to pay toward the fee.

 

If You Have Any Questions

If you have any questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at[FO phone number] . We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

 

[Field Office Address
City, ST, ZIP]

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

 

[Name]
Regional Commissioner

[Show at bottom of first page of notice]

Enclosure:

SSA Pub. No. 70-10281

EXHIBIT 9 Reconsideration Disability Denial - DAA Is Material - Title XVI

 

Language:

You asked us to take another look at   (1)   claim for Supplemental Security Income (SSI) payments. Someone who did not make the first decision reviewed   (2)   case, including any new facts we received. Based on this review, we found that our first decision was correct. The law says we cannot pay disability benefits based on   (3)   . Because    (4)   health problems are based on   (5)   , we cannot pay   (6)   any benefits.

 

Fill-ins:

1. 1. 

   your/[Claimant name, possessive]

2. 2. 

   your/[Claimant name, possessive]

3. 3. 

   drug addiction/alcoholism/drug addiction and alcoholism

4. 4. 

   your/his/her

5. 5. 

   drug addiction/alcoholism/drug addiction and alcoholism

6. 6. 

   you/him/her

    

The Decision on   (1)   Case

 

  (2)  

 

Fill-ins:

1. 1. 

   Your/[Claimant name, possessive]

2. 2. 

   [Personalized Denial Language]

   [Including decision paragraph: (cleared for initial disability denials) - See Concurrent Notice, above]

    

About the Decision

Please remember that there are many types of disability programs, both government and private, which use different rules. A person may be receiving benefits under another program and still not be entitled under our rules. This may be true in this case.

 

OPTIONAL PARAGRAPH:

The following paragraph will be used when the field office takes an SSI application and determines the individual is not entitled to any or additional title II benefits. As a result, the FO does not take a supplemental title II application, but alerts the DDS to use this paragraph. It is patterned after paragraph 1598.

 

Information about Social Security Benefits

The application you filed for SSI was also a claim for Social Security benefits. We looked into this, and decided   (1)   can't get any Social Security benefits   (2)   . If you disagree with this decision, you have the right to appeal. The appeal is described in this letter.

 

Fill-ins:

1. 1. 

   you/[Claimant name]

2. 2. 

   except the benefit you are already getting/except the benefit she is already getting/except the benefit he is already getting/NULL

    

Information About Medicaid   (1)  

 

  (2)  

 

  (3)  

 

Fill-ins:

1. 1. 

   And Other Benefits /NULL

2. 2. 

   Choice 1 - MDC012
   Choice 2 - MDC013
   Choice 3 -MDC014
   Choice 4 - MDC016

3. 3. 

   Choice 1 - SAS001
   Choice 2 - NULL

    

If You Disagree With The Decision

If you disagree with the decision that   (1)   health problems are based on   (2)   , you have the right to request a hearing. A person who has not seen your case before will look at it. That person is an Administrative Law Judge (ALJ). The ALJ will review your case again and consider any new facts you have before deciding your case.

• •

  You have 60 days to ask for a hearing.

• •

  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 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 a hearing.

• •

  You have to ask for a hearing in writing. We will ask you to sign a form HA-501-U5, called “Request for Hearing.” Contact one of our offices if you want help.

   

Fill-ins:

1. 1. 

   your/his/her

2. 2. 

   drug addiction/alcoholism/drug addiction and alcoholism

    

How The Hearing Process Works

The ALJ will mail you a letter at least 20 days before the hearing to tell you its date, time and place. The letter will explain the law in your case and tell you what has to be decided. Since the ALJ will review all the facts in your case, it is important that you give us any new facts as soon as you can.

The hearing is your chance to tell the ALJ why you disagree with the decision in your case. You can give the ALJ new evidence and bring people to testify for you. The ALJ also can require people to bring important papers to your hearing and give facts about your case. You can question these people at your hearing.

Please read the enclosed pamphlet “Your Right To An Administrative Law Judge Hearing And Appeals Council Review Of Your Social Security Case.” It has more information about the hearing.

 

It Is Important To Go To The Hearing

It is very important that you go to the hearing. If for any reason you can't go, contact the ALJ as soon as possible before the hearing and explain why. The ALJ will reschedule the hearing if you have a good reason.

If you don't go to the hearing and don't have a good reason for not going, the ALJ may dismiss your request for a hearing.

 

New Application

You have the right to file a new application at any time, but filing a new application is not the same as appealing this decision. If you disagree with this decision and you file a new application instead of appealing,   (1)    might lose some benefits, or not qualify for any benefits. So, if you disagree with this decision, you should ask for an appeal within 60 days.

 

Fill-in:

1. 1. 

   you/[Claimant name]

    

If You Want Help With Your Hearing

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 you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it.

 

If You Have Any Questions

If you have any questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at[FO phone number] . We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

 

[Field Office Address
City, ST, ZIP]

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

 

[Name]
Regional Commissioner

 

[Show at bottom of first page of notice]

Enclosure:

SSA Pub. No. 70-10281

EXHIBIT 10 REMAINDER OF NOTICE - TITLE II

 

If You Disagree With The Decision

If you disagree with the decision, you have the right to request a hearing. A person who has not seen your case before will look at it. That person is an Administrative Law Judge (ALJ). The ALJ will review your case again and consider any new facts you have before deciding your case.

• •

  You have 60 days to ask for a hearing.

• •

  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 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 a hearing.

• •

  You have to ask for a hearing in writing. We will ask you to sign a form HA-501-U5, called “Request for Hearing.” Contact one of our offices if you want help.

Please read the enclosed pamphlet, “Your Right to An Administrative Law Judge Hearing and Appeals Council Review of Your Social Security Case.” It contains more information about the hearing.

 

If You Want Help With Your Hearing

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 you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a lawyer, we will withhold up to 25 percent of any past due Social Security benefits to pay toward the fee.

 

If You Have Any Questions

[Appropriate referral paragraph]

 

Enclosure:

SSA Pub. No. 70-10281

 

Referral Paragraphs:

UNDER THE CAPTION:

 

If You Have Any Questions

 

Choice 1: USE: Notice prepared by DDS

If you have any questions, call us toll-free at 1-800-772-1213 or call your local Social Security office at (TRIDE fill-in). We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

 

Field Office Address
City ST ZIP

 

If you do call or visit an office, please have this letter with you. It will help us answer your questions.

 

Choice 2: USE: Notice prepared by FO

 

If you have any questions, you may call, write, or visit any Social Security office. If you call or visit our office, please have this letter with you and ask for (name). The telephone number is shown at the top of this letter.