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