TN 49 (02-06)
NL 00703.956 Expedited Reinstatement (EXR) Award Notice
For more information on Aurora UTIs, see the MAMPSC Aurora UTI
Library Search Page
AURORA notice UTI E3956
Social Security Administration
Retirement,
Survivors and Disability
Insurance
Date:
Claim
Number:
Addressee Name
Street Address
City, ST Zip code
We have approved your request to start your disability benefits again. We can start
to pay you for the month of __(1)__.
Fill-in:
(1) mm/yy
What We Will Pay And When
You will soon receive a check for $__(1)__, which is the money you are due through
__(2)__.
After that, you will receive $__(3)__ on or about the __(4)__ of each month.
Fill-ins:
(1) custom dollar amount
(2) mm/yy
(3) custom dollar amount
(4) custom
Optional
Paragraph
You may have received provisional (temporary) benefits for up to six months beginning
with the month you filed your request. We will reduce reinstated benefits payable
for a month by the amount of any provisional (temporary) benefit paid to you for that
month.
How We Will Pay You
Multiple Mandatory Choice 1 of 3
The information we have shows that you need help managing your money and meeting your
daily needs. Because of this information, we plan to send your benefits to __(1)__.
We call this __(2)__ your representative payee.
Fill-ins:
(1) Custom – Rep Payee’s Full Name
(2) person or organization
Multiple Mandatory Choice 2 of 3
__(1)__ and any future payments will go to the financial institution you selected.
Please let us know if you change your mailing address, so we can send you letters
directly.
Fill-Ins:
(1) This or These
Multiple Mandatory Choice 3 of 3
We __(1)__ sending your regular monthly check of $__(2)__ to __(3)__ around __(4)__.
Fill-Ins:
(1) will begin/began
(2) Custom – monthly payment amount
(3) Custom – name of payee
(4) Custom – date payments began mm/dd/yyyy
Optional Header
Overpayment Information
Optional Paragraph
We are writing to you about an overpayment __(1)__ us. The amount of the overpayment
is $__(2)__. We have written to you about this before, but you have not settled this
matter. You should repay this overpayment now, or contact us about how you will pay
us back.
Fill-Ins:
(1) you owe/Client Name owes
(2) Custom – overpayment dollar amount
Optional Paragraph
You have the right to request waiver of recovery of __(1)__ overpayment at any time.
Your request for waiver can be approved and you will not have to repay the overpayment
if we determine it was not your fault in any way and either __(2)__ repayment would
prevent you from meeting __(3)__ necessary living expenses; or __(4)__ repayment would
be unfair for some other reason.
Whether or not you request a waiver, if you disagree with any of our determinations,
you may request a reconsideration within 60 days of the date you receive this notice.
If you have additional evidence to support your claim, you should submit it with your
request.
Fill-Ins:
(1) your/Client Name possessive
(2) your/Client Name possessive
(3) your/his/her/Client name possessive
(4) your/his/her/Client name possessive
Optional Paragraph
If you request a waiver or reconsideration within 30 days of the date of this notice,
you will no have to repay __(1)__ overpayment until a review of __(2)__case is completed.
The review is described in more detail on the attached Form SSA-3105, Important Information
About Your Appeal and Waiver Rights.
Please call, write, or visit any Social Security office if you want to request reconsideration
or if you believe you should not have to repay the overpayment and want to request
a waiver. The people there will be glad to help you complete the forms for reconsideration
(SSA-561-U2, Request for Reconsideration) and/or waiver (SSA-632-BK, Request for Waiver
of Overpayment Recovery or Change in Repayment Rate).
Fill-Ins:
(1) your/client name possessive
(2) your/client name possessive
Optional Header
Information About Medicare
Multiple Optional Choice 1 of 11
We have changed the date of __(1)__ entitlement to __(2)__ insurance under Medicare.
__(3)__ new entitlement date is __(4)__. We will take any premiums due for the insurance
out of __(5)__ next payment.
Fill-ins:
(1) your/client name possessive
(2) Custom
(3) your/his/her/client name possessive
(4) Custom, MMMM dd,yyyy
(5) your/his/her/client name possessive
Multiple Optional Choice 2 of 11
We charge a monthly premium for your medical insurance. The rates are shown below:
Amount: __(1)__
Date Beginning: __(2)__
Fill-ins:
(1) Custom
(2) Custom, MMMM dd,yyyy
Multiple Optional Choice 3 of 11
This medical insurance premium includes a penalty because you enrolled later than
you could have.
Multiple Optional Choice 4 of 11
We will send __(1)__ a Medicare card. __(2)__ should take this card with __(3)__ when
__(4)__ __(5)__ medical care. If __(6)__ __(7)__ medical care before receiving the
card and __(8)__ coverage has already begun, use this letter as proof that __(9)__
covered by Medicare.
Fill-ins:
(1) you/him/her/Client name
(2) you/he/she/Client name
(3) you/him/her/Client name
(4) you/he/she/Client name
(5) need/needs
(6) you/he/she/Client name
(7) need/needs
(8) your/his/her/Client name possessive
(9) you are/he is/she is/Client name is
Multiple Optional Choice 5 of 11
If you do not want medical insurance, please complete the enclosed card and return
it to us in the envelope we have provided. You will need to do this by the date shown
on the card. If you decide you do not want the insurance, we will return any premiums
that you have paid.
Multiple Optional Choice 6 of 11
You are entitled to hospital and medical insurance under Medicare beginning __(1)__.
Fill-ins:
(1) Custom, MMMM dd,yyyy
Multiple Optional Choice 7 of 11
You are entitled to medical insurance under Medicare beginning __(1)__.
Fill-ins:
(1) Custom, MMMM dd,yyyy
Multiple Optional Choice 8 of 11
We did not give __(1)__ earlier medical insurance because we did not process it timely.
If you want to have these benefits earlier, you can choose medical insurance benefits
beginning __(2)__. If you want this benefit to start earlier, you must do the following
things within 30 days after the date of this notice:
-
•
tell us in writing that you want medical insurance benefits beginning __(3)__;
-
•
pay us __(4)__. This covers the premiums due from __(5)__ through __(6)__; or
-
•
tell us we can withhold this amount from the check.
If you want the benefits beginning __(7)__ but would find it hard to pay the premium
amount in a lump sum, ask us about other ways to pay the money.
Fill-ins:
(1) you/client name
(2) custom, MMMM dd,yyyy
(3) custom, MMMM dd,yyyy
(4) custom
(5) custom, MMMM dd,yyyy
(6) custom, MMMM dd,yyyy
(7) custom, MMMM dd,yyyy
Multiple Optional Choice 9 of 11
Another individual or organization will pay the premiums for __(1)__ Medicare coverage
beginning __(2)__. Even though the bill will be sent to them, you are still responsible
for seeing that __(3)__ premiums are paid. If they decide that they will no longer
send the payments, we will start to send the premium notices to you.
Fill-ins:
(1) your/Client name possessive
(2) custom, MMMM dd, yyyy
Multiple Optional Choice 10 of 11
The Railroad Retirement Board is handling your hospital and medical insurance under
Medicare.
Multiple Optional Choice 11 of 11
It is important for you to know, however that Medicare cannot pay any of the hospital
or medical bills unless you receive your medical care in the United States (including
Puerto Rico, the Virgin Islands, Guam, and American Samoa). Under certain, limited
circumstances, medical services provided in Canada or Mexico also may be covered by
Medicare, but only if you are living in the United States. THEREFORE, UNLESS YOU BELIEVE
THAT YOU MAY BE RETURNING TO THE UNITED STATES IN THE NEAR FUTURE EITHER TO LIVE OR
TO RECEIVE MEDICAL CARE, IT IS PROBABLY NOT TO YOUR ADVANTAGE TO ENROLL IN MEDICAL
INSURANCE AT THIS TIME.
You may wish to read the enclosed leaflet, which describes hospital insurance and
medical insurance under Medicare. If you decide medical insurance will be of no value
to you now but you change your mind later, you can enroll during the first 3 months
of any year, and your coverage then would begin in July of the year you enroll. Your
monthly premium would be 10 percent higher for each 12-month period that you could
have been enrolled but were not.
If You Return To Work
Generally we consider work to be substantial and gainful if the monthly earnings are
over __(1)__ per month (for the year __(2)__). In deciding whether your work is substantial
and gainful, we consider how much you actually earn, the nature of your job duties,
the skills and experience you need to do the job, expenses related to your disability,
and how much you actually earn. If you are self-employed, we may give more consideration
to the kind and value of your work, including your part in the management of the business,
than to your actual income alone.
As long as your medical condition still meets our definition of a disabling impairment,
we can pay reinstated benefits for each month your work is not substantial and gainful
until you have received 24 months of payable benefits. Benefits will not be payable
for a month(s) in which your work is substantial and gainful, if that month occurs
during the 24 month initial reinstatement period. These 24 payable months do not have
to be in a row. Even if you are not receiving payments because of work, your Medicare
coverage will continue.
At the end of these 24 months, you may be eligible for additional work incentives,
such as a trial work period, and another extended period of eligibility for Medicare.
Please see the enclosed pamphlet, “Working While Disabled,” for more information about
work incentives.
Fill-ins:
(1) Custom
(2) Custom, YYYY
Your Responsibilities
You must tell us right away about any changes that may affect your benefits. You should
tell us if:
-
•
You change your mailing address;
-
•
You return to work or you increase your work hours;
-
•
Your doctor says your condition has improved;
-
•
You plan to leave the United States for 30 days or more;
-
•
You have been convicted of a criminal offense; or
-
•
You marry and your benefits have been reinstated as either a disabled widow/widower
or a disabled adult child.
If You Disagree With The Decision
If you disagree with the decision, you have the right to appeal. We will review your
case again 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 if you wait 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.
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 benefits to pay toward the fee.
If You Have Any Questions
Mandatory Choice 1 of 2
For general information about Social Security we invite you to visit our website at
www.socialsecurity.gov on the Internet. For general questions and specific questions
about __(1)__ case, you may call us toll-free at 1-800-772-1213, or call your local
Social Security office at __(2)__ and ask for __(3)__. We can answer most questions
over the phone. If you are deaf or hard of hearing, you may call our TTY/TDD number
__(4)__. If you do call or visit an office, please have this letter with you. It will
help us answer your questions.
Fill-ins:
(1) your/client’s name possessive
(2) user’s phone number
(3) user’s name
(4) TDD phone number
Mandatory Choice 2 of 2
We invite you to visit our web site at www.socialsecurity.gov on the Internet to find
general information about Social Security. If you have any specific questions, you
may call us toll-free at 1-800-772-1213, or call your local office at __(1)__. We
can answer most questions over the phone. If you are deaf or hard of hearing, you
may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security
office. The office that serves your area is located at:
__(2)__
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 when you arrive at
the office.
Fill-ins:
(1) Servicing Office Phone Number
(2) Service Office Name and address
Enclosure:
Pub 05-10095 ‘Working While Disabled-How Can We Help’