To view the form, go to OS 15025.020.

To review the form, go to OS 15025.025.

To review Exhibit 4, select View PDF Version below.

Notices Available in DPS

1. 1. 

   Title II/Title XVI Cover/Close-Out Notice

2. 2. 

   Title II Award Notice

3. 3. 

   Title II Medical Denial Notice

4. 4. 

   Title II Technical Denial Notice

5. 5. 

   Title II Reconsideration Denial Notice

6. 6. 

   Title II IRP Benefit Change Notice

7. 7. 

   Title II IRP Due Process Notice

1. 8. 

   Title II End of IRP Notice

Notices available in Aurora

Title II IRP Benefit Change Notice (UTI E3954, see NL 00703.954.)

Title II Award Notice (UTI E3956, see NL 00703.956.)

Notices to be completed manually:

1. 1. 

   Title XVI notice of reinstatement

2. 2. 

   Title XVI notice of technical denial

3. 3. 

   Title XVI notice of medical denial based on “not same as or related”

4. 4. 

   Title XVI notice of medical denial based on MIRS

5. 5. 

   Title XVI couples notices

6. 6. 

   Title XVI notice of suspense of provisional payments for normal suspense reasons

Social Security Administration

Retirement, Survivors, and Disability Insurance Notice of Denial of Reinstatement Request

 

                                                                                           Date:

                                                                                           Claim Number:

 

Addressee Name

Street Address

City, ST Zip code

 

 

We are writing about your request for reinstatement of Social Security disability benefits. To be entitled to reinstated benefits, your medical condition must prevent you from performing substantial gainful work. In addition, your current impairment must be the same as, or related to, the impairment that was the basis for your previous entitlement to disability benefits.

 

After reviewing all of the information carefully, we have decided that:

 

Option 1 (*insert if individual has medically improved based on MIRS standard) [UTI=RNS016]

your health has improved since we last reviewed your case. You are able to work, and are not considered disabled under our rules. We are therefore denying your request for reinstated benefits.

 

Option 2 (*insert if individual’s current impairment is not the same as or related to the impairment that was the basis for their previous entitlement) [UTI=RNS017]

Your current impairment is not the same as, or related to, the impairment that was the basis for your previous entitlement to disability benefits. We are therefore denying your request for reinstated benefits.

 

We have enclosed a page that gives you more information on how we made the decision on your case.

 

About the Decision

Doctors and other trained staff looked at your case and made this decision. They work for your State but use our rules.

 

Please remember that there are many types of disability programs, both government and private, that 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 your case.

 

When Your Provisional Payments End (Use if the individual was receiving provisional payments)

 

Under the law, your provisional (temporary) benefits end with whichever month is the earliest:

 

• –

  The month we make a decision about your request for reinstated benefits; or

• –

  The month you return to work and perform substantial gainful work; or

• –

  The month before you reach full retirement age; or

• –

  The fifth month following the month you made your request.

 

If you are still receiving provisional benefits, then the last provisional benefit you may receive is for month/yyyy (date of notice).

 

Information About Medicare Option 1 (*insert if the individual is receiving Medicare only as part of their provisional benefits) [UTI=HIB158]

If you received Medicare coverage as part of provisional benefits, your Medicare will end. We will send you a separate notice to tell you when your Medicare will end.

 

Option 2 (*insert if the individual is receiving extended Medicare AND they are determined to have medically improved based on MIRS) [UTI=HIB167]

If you are receiving extended Medicare coverage, your Medicare will end. We will send you a separate notice to tell you when your Medicare will end.

 

Option3 (*insert if the individual is receiving extended Medicare or MQGE AND they are determined to not have an impairment the same as or related to the impairment that was basis for previous entitlement) [UTI=HIB159]

This decision does not affect your Medicare benefits.

 

Option 4 (*insert if the individual had Premium-HI (DWI) at the time of EXR request AND they are determined to have medically improved based on MIRS) [UTI=HIB168]

If you had premium-hospital insurance (Part A) and/or medical insurance (Part B) coverage when you started receiving provisional benefits, your Medicare coverage will end. We will send you a notice to tell you when your Medicare will end.

 

Option 5 (*insert if the individual had ESRD Medicare) [UTI=HIB169]

This decision does not affect your Medicare hospital insurance (Part A) and/or medical insurance (Part B) coverage that are based on your end stage renal disease. Your Medicare will continue.

 

Option 6 (*insert if the individual was converted to AGED Medicare during the provisional period) [UTI=HIB172]

Since you are age 65 or older, your Medicare coverage will continue.

 

Option 7 (*insert if the individual had MQGE Medicare at time of EXR request AND they are determined to have medically improved based on MIRS) [UTI=HIB173]

If you had Medicare hospital insurance (Part A) and/or medical insurance (Part B) during the provisional benefit period based on your government employment, your Medicare coverage will end. We will send you a notice to tell you when your Medicare will end.

 

Option 8 (*insert if the individual has Premium HI AND they are determined to not have an impairment the same as or related to the impairment that was basis for previous entitlement) [UTI=HIB 174]

While you were receiving provisional payments, you were not required to pay premiums for your Medicare coverage. You may still be eligible to receive Medicare coverage, but you will again be required to pay the premium for this coverage. If you wish to continue receiving your Premium Medicare coverage, you must contact your local field office to request that this coverage be reinstated. Contact information for your local field office is contained at the end of this letter.

 

If You Disagree With the Decision

If you disagree with the decision, 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 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 they 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 Don’t Appeal But Instead Request Reinstated Benefits or Apply for Benefits

You have the right to file a new request for reinstatement of benefits. You also have the right to file an application for benefits at any time. However, doing either of these things is not the same as appealing this decision. If you disagree with this decision and you file a new request for reinstated benefits or an application for benefits instead of appealing, you might lose some benefits, or not qualify for any benefits. This is so even if you file an application within the 6-month period described below. So if you disagree with this decision, you should ask for an appeal within 60 days.

 

You can ask for an appeal of this decision and, at the same time, file an application for benefits or a new request for reinstated benefits.

 

If You Decide to Apply for Benefits

If you decide to apply for Social Security disability benefits and you file an application within 6 months from the date of this notice, we will use *F1, as the filing date of your new application. This is the date you requested reinstatement of your benefits. We will not use that date as the filing date if you file your application later than 6 months from the date of this notice. Thus, if you decide to apply for benefits, you may lose benefits if you do not apply within this 6-month time period.

 

Fill-Ins:

*F1 mm/dd/yyyy

 

If You Have Any Questions

We invite you to visit our website at SSA.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 Social Security 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) __

__ (3) __

__ (4) __

__ (5) __

 

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

Field Office phone number

First line of Field Office address

Second line of Field Office address

Third line of Field Office address

Fourth line of Field Office address

Fifth line of Field Office address

 

 

 

                             Regional Commissioner

 

Enclosure:

Explanation of Decision

 

 

 

Social Security Administration

Retirement, Survivors, and Disability Insurance Notice of Denial of Reconsideration Request

 

 

                                                                                                   Date:

                                                                                                   Claim Number:

 

Addressee Name

Street Address

City, ST Zip code

 

 

We are writing about your request to reconsider our previous decision that you are not entitled to reinstated Social Security disability benefits.

 

We find that the original decision was correct and in accordance with the law and regulations. The enclosed Reconsideration Determination fully explains the decision reached.



The person who made this reconsideration decision is not the same person who made the original decision. This person made an independent and thorough review of the relevant evidence on record about your claim.

 

Information About Your Medicare (*insert only if the individual currently has extended Medicare, Premium-HI, ESRD Medicare, or now has AGED Medicare. This paragraph should not be included when the person is determined to not be disabled based on MIRS)

This decision does not affect your Medicare benefits. [UTI=HIB159]

 

If You Disagree with this Decision

If you disagree with this 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 look at 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 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 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.

 

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 they 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 Don’t Appeal But Instead Request Reinstated Benefits or Apply for Benefits

You have the right to file a new request for reinstatement of benefits. You also have the right to file an application for benefits at any time. However, doing either of these things is not the same as appealing this decision. If you disagree with this decision and you file a new request for reinstated benefits or an application for benefits 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.

 

You can ask for an appeal of this decision and, at the same time, file an application for benefits or a new request for reinstated benefits.

 

If You Have Any Questions

We invite you to visit our website at SSA.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 Social Security 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) __

__ (3) __

__ (4) __

__ (5) __

 

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

Field Office phone number

First line of Field Office address

Second line of Field Office address

Third line of Field Office address

Fourth line of Field Office address

Fifth line of Field Office address

 

 

 

 

 

                         Regional Commissioner

 

 

 

 

Social Security Administration

Retirement, Survivors, and Disability Insurance Notice of Denial of Reinstatement Request

 

 

                                                                                                     Date:

                                                                                                     Claim Number:

 

Addressee Name

Street Address

City, ST Zip code

 

 

We are writing about your request for reinstatement of Social Security disability benefits. To be entitled to reinstated benefits, you must:

 

• –

  have previously been entitled to disability insurance benefits, disabled widow/(er) or surviving divorced spouse benefits, or disabled adult child benefits; and

• –

  had your previous entitlement benefits terminated because you began performing substantial gainful work; and

• –

  have an impairment(s) that is the same as, or related to, the impairment(s) which was the basis for your prior entitlement; and

• –

  be unable to perform substantial gainful work because of your medical condition; and

• –

  have filed your request for reinstated benefits within 60 months from the month your previous entitlement to benefits was terminated.

 

Based on a review of the evidence in your case, you do not qualify for reinstated benefits. This is because

 

(*choose one of the following)

• –

  You were not previously entitled to disability insurance benefits, or widow/(er), surviving divorced spouse, or disabled adult child benefits, that were based on you having a disability. [UTI=RNS008]

• –

  Your previous entitlement to disability benefits was terminated month/yyyy (date of termination of previous entitlement) for a reason other than the performance of substantial gainful work. [UTI=RNS009]

• –

  The work you were doing in the month you filed this request was substantial gainful work. [*Insert personalized language that details SGA earnings in month of filing] [UTI=RNS010]

• –

  Your request for reinstated benefits was filed more than 60 months from the month your entitlement to benefits was previously terminated. You filed your request on (mm/dd/yy) and your entitlement to benefits were previously terminated on (mm/dd/yy). You did not show good cause for the late filing. [UTI=RNS011]

• –

  You had reached full retirement age in the month you filed your request for reinstated benefits and are now eligible for retirement benefits. [UTI=RNS012]

 

Information About Substantial Work (*include this paragraph only when denial is based on the performance of SGA during the month the EXR request was filed)

Generally, substantial gainful work is physical or mental work you are paid to do. Work can be substantial even if it is part-time. We consider the nature of your job duties, the skills and experience you need to do the job, and how much you actually earn.



Usually, we consider work to be substantial and gainful if monthly earnings, after allowable deductions, average over $810 a month (or $800 per month before January 1, 2004). 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 income alone.



Your work now may be different than before your disability began. It may not be as hard to do and your pay may be less. However, we may still consider your work to be substantial and gainful under our rules.

 

When Your Provisional Payments End (Use if the individual was receiving provisional payments)

Under the law, your provisional (temporary) benefits end with whichever month is the earliest:

 

• –

  The month we make a decision about your request for reinstated benefits; or

• –

  The month you return to work and perform substantial gainful work; or

• –

  The month before you reach full retirement age; or

• –

  The fifth month following the month you made your request.

 

If you are still receiving provisional benefits, then the last provisional benefit you may receive is for month/yyyy (date of notice).

 

Information About Your Medicare

Option #1 (*insert if the individual was receiving Medicare only as part of their provisional benefits) [UTI=HIB158]

If you received Medicare coverage as part of provisional benefits, your Medicare will end. We will send you a separate notice to tell you when your Medicare will end.

 

Option #2 (*insert if the individual has extended Medicare, ESRD Medicare, MQGE, or now has AGED Medicare) [UTI=HIB159]

This decision does not affect your Medicare benefits.

 

Option 3 (*insert if the individual has Premium HI) [UTI=HIB174]

While you were receiving provisional payments, you were not required to pay premiums for your Medicare coverage. You may still be eligible to receive Medicare coverage, but you will again be required to pay the premium for this coverage. If you wish to continue receiving your Premium Medicare coverage, you must contact your local field office to request that this coverage be reinstated. Contact information for your local field office is contained at the end of this letter.

 

If You Disagree With the Decision

If you disagree with the decision, 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 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 they 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. {3100E}

 

If You Don’t Appeal But Instead Request Reinstated Benefits or Apply for Benefits

You have the right to file a new request for reinstatement of benefits. You also have the right to file an application for benefits at any time. However, doing either of these things is not the same as appealing this decision. If you disagree with this decision and you file a new request for reinstatement or an application for benefits instead of appealing, you might lose some benefits, or not qualify for any benefits. This is so even if you file an application with the 6-month period described below. So if you disagree with this decision, you should ask for an appeal within 60 days.

 

You can ask for an appeal of this decision and, at the same time, file an application for benefits or a new request for reinstated benefits

 

If You Decide to Apply for Benefits

 

If you decide to apply for Social Security disability benefits and you file an application within 6 months from the date of this notice, we will use *F1, as the filing date of your new application. This is the date you requested reinstatement of your benefits. We will not use that date as the filing date if you file your application later than 6 months from the date of this notice. Thus, if you decide to apply for benefits, you may lose benefits if you do not apply within this 6-month time period. {New UTI}

 

Fill-ins:

*F1 mm/dd/yyyy

 

If You Have Any Questions

We invite you to visit our website at SSA. 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 Social Security 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) __

__ (3) __

__ (4) __

__ (5) __

 

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

Field Office phone number

First line of Field Office address

Second line of Field Office address

Third line of Field Office address

Fourth line of Field Office address

Fifth line of Field Office address

 

 

 

 

 

 

 

                            Regional Commissioner