• •

  Enter the claimant's full name as shown on the cessation notice and, if different, the name of the number holder (NH).

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  Enter the claimant's Social Security number (SSN) next to their name regardless of whether it is the claim number on which the claimant files the SSA-789.

• •

  Enter the Wage Earner’s SSN only if the claimant's SSN is different from the wage earner.

• •

  Complete the spouse’s name and SSN only if the reconsideration request involves a Title XVI case and the spouse is not the NH.

When the Request for Reconsideration-Disability Cessation involves more than one SSN, enter all SSNs on the form. For example, when the individual receives a cessation notice(s) on more than one benefit, they would generally file the request for reconsideration on all entitlement claims.

NOTE: In Title XVI and concurrent cases, it is permissible to input the reconsideration request directly in the claim path of the Modernized Supplemental Security Income Claims System (MSSICS) and fax a copy of the printed appeal summary into eView under an SSA-789 coversheet. See DI 12026.020 Field Office (FO) Responsibilities When an Individual Wants to Request Reconsideration of a Medical Continuing Disability Review (CDR) Determination.

• •

  Check the appropriate box to indicate which type(s) of benefit the individual is appealing - title II Social Security Disability Insurance (DI) or Title XVI Supplemental Security Income (SSI).

• •

  Check both boxes (under each benefit) if the reconsideration request involves a concurrent claim.

Enter the reason for the reconsideration request. Be as specific as possible.

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  Briefly describe why the individual believes they are still disabled, or what part of the notice they think is inaccurate.

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  Avoid writing, “I am still disabled and cannot work.” This statement does not provide specific information about the individual’s reason for requesting reconsideration.

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  The individual must provide a reason for filing late if the date of the cessation notice exceeds 65 days.

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  For additional information, see

  • –

    DI 12026.015 Field Office (FO) Actions when an Individual Disagrees with the Medical Cessation or Adverse Medical Reopening Determination

  • –

    GN 03101.020 Good Cause for Extending the Time Limit to File an Appeal

Enter any additional information the individual wishes to submit as follows:

• •

  List any information the individual or someone on their behalf, submits or plans to submit.

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  Enter any documentation that will be provided with form SSA-789, and attach additional pages if needed.

• •

  Instruct the individual to submit any new information as early as possible in the disability hearing process.

NOTE: Explain that waiting until the hearing to submit additional information may delay the determination because the disability hearing officer (DHO) may need to return the case to the disability determination services (DDS) to develop the new evidence.

The SSA-789 has two boxes to indicate whether the individual wishes to appear at the hearing.

1. a. 

   Check the first box if the individual, and/or their representative, wishes to appear at the hearing. When an interpreter is required:

   1. 1. 

      Check the box indicating the need for an interpreter and specify the language. For more information on interpreters for individuals, see GN 00203.011H Special Interviewing Situations: Limited English Proficiency (LEP) or Language Assistance Required.

   2. 2. 

      If the individual provides their own interpreter, explain that the interpreter must be able to translate technical medical terminology and concepts.

   3. 3. 

      If the individual provides an interpreter and the interpreter appears to be unqualified (for example, a young child), prepare an electronic or paper version of the report of contact, form SSA-5002 (Report of Contact) for the case folder explaining the situation.

2. b. 

   Check the second box if the individual or appointed representative does not wish to appear at the hearing. In addition, ask the individual or appointed representative to sign the SSA-773-U4 (Waiver of Right to Appear - Disability Hearing). For more information regarding completion of the SSA-773-U4, see DI 12026.022 SSA-773-U4 Waiver of Right to Appear – Disability Hearing.

NOTE: There is no need to complete all of the identifying information on the SSA-773-U4 if filed together with the SSA-789. Complete only the name, claim number(s), and obtain the signature. If the individual decides, subsequent to filing, to waive the appearance, complete the entire SSA-773-U4.

The individual, their appointed representative, representative payee, or other third party on behalf of the individual may sign the form. However, a signature is not required to process the reconsideration request under certain conditions. See DI 12026.021B.6.c in this section below for an explanation.

1. a. 

   When the individual has an appointed representative, enter the appointed representative's name and address in the designated spaces on the SSA-789.

2. b. 

   If the individual lists an appointed representative on the SSA-789, ensure an SSA-1696-U4 (Claimant's Appointment of Representative), is in the case folder. For information regarding the appointment of a representative, see GN 03910.040 Appointment and Revocation of Appointment of Representative.

3. c. 

   No signature is required on the SSA-789 to process a reconsideration request if we have a statement that clearly shows dissatisfaction with an initial determination. For additional information regarding the informal request for a hearing, see GN 03103.010 The Hearing Process.

4. d. 

   If applicable, have witnesses sign the form, and complete the address information in the designated spaces. Check the first box if the individual, and/or their representative, wishes to appear at the hearing.

Complete only the items that apply. For items that do not apply, enter N/A (not applicable); do not leave these spaces blank.

a. FO code

Check the box next to the FO code and enter the code as follows:

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  Enter the servicing FO code.

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  If the individual files a request for reconsideration at a location that is not the individual's servicing FO, look up the servicing FO code using the Detailed Office/Organization Resource System (DOORS), and enter it on the SSA-789. For additional information on DOORS, see MS 01301.002 Detailed Office/Organization Resource System (DOORSMAINMENU)

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  Enter the International Program Service Center (INTPSC) code as the FO code for foreign claims.

b. Benefit continuation

Check the box next to, ‘Benefit Continuation,’ if the individual's benefit payments will continue.

c. Foreign language notices

Check the box next to, ‘Foreign Language Notice,’ if the individual or applicant meets the criteria for receiving this notice (for example, only speaks Spanish). Notate the desired language in the designated space.