A separate election statement (SSA-795) is required at each level of appeal.
The election statement must be specific to the claim type:
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Title II Benefit Continuation Election Statement
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Auxiliary Benefit Continuation Election Statement
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Title XVI and Concurrent Title II/Title XVI - Benefit Continuation Election Statement
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Extended Period of Eligibility (EPE) Continuation Election Statement
IMPORTANT: In concurrent cases, complete Exhibits 1 and 3, DI 12095.171.
See SSA-795 Election Statement - Exhibits, DI 12095.171 for the exhibits of the specific election statements. In concurrent cases, complete
Exhibits 1 and 3.
NOTE: Explain to the individual that the election statement is required whether he/she
elects or declines SBC.