TN 4 (01-97)
DI 90070.900 DAA (P.L. 104-121) Exhibits
EXHIBIT 1 |
WAYS TO APPEAL -- TITLE XVI |
EXHIBIT 2 |
CONCURRENT TITLE II, TITLE XVI -- DENIAL OF INITIAL DISABILITY CLAIM -- DAA IS MATERIAL |
EXHIBIT 3 |
DENIAL OF INITIAL DISABILITY CLAIM -- DAA IS MATERIAL -- TITLE II |
EXHIBIT 4 |
DENIAL OF INITIAL DISABILITY CLAIM -- DAA IS MATERIAL -- TITLE XVI |
EXHIBIT 5 |
DECISION PARAGRAPH FOR PDN -- DENIAL -- DAA IS MATERIAL |
EXHIBIT 6 |
SAMPLE NOTICE -- TITLE XVI DENIAL -- DAA IS MATERIAL |
EXHIBIT 7 |
RECONSIDERATION DISABILITY DENIAL -- DAA IS MATERIAL CONCURRENT TITLE II -- TITLE
XVI
|
EXHIBIT 8 |
RECONSIDERATION DISABILITY DENIAL -- DAA IS MATERIAL -- TITLE II |
EXHIBIT 9 |
RECONSIDERATION DISABILITY DENIAL -- DAA IS MATERIAL -- TITLE XVI |
EXHIBIT 10 |
REMAINDER OF NOTICE - TITLE II |
EXHIBIT 1 “WAYS TO APPEAL” - SSI
HOW TO APPEAL YOUR SUPPLEMENTAL SECURITY INCOME (SSI) DISABILITY DECISION UNDER
P.L. 104-121
There are different ways to appeal. The person who gave you this form can tell how
these appeals work. You can have a lawyer, friend, or someone else help you with your
appeal.
Here are different ways to appeal:
-
You can give us more facts to add to your file. Then we'll decide your case again.
You don't meet with the person who decides your case.
-
2.
FACE-TO-FACE DUE PROCESS EVIDENTIARY HEARING
You'll meet with the person who will decide your case. You can tell that person why
you think you're right. You can give us more facts to help prove you're right. You
can bring other people to help explain your case.
Plus, we can make people come to your meeting to help prove you're right. We can do
this even if they don't want to help you. You can question these people at your meeting.
Now you know the two kinds of appeals. We'll help you fill out your appeal request.
There are groups that can help you with your appeal. Some can give you free help with
your appeal. We can give you the names of these groups.
EXHIBIT 2 Concurrent TII, T16 - DENIAL OF INITIAL DISABILITY CLAIM - DAA IS MATERIAL
-- (Patterned on SSA-L442)
Language:
We are writing about (1) claims for Social Security and Supplemental Security Income (SSI) disability benefits.
Based on a review of
(2) health problems, (3) not qualify for benefits on either claim. The law says we cannot pay disability benefits
based on (4) . Because (5) health problems are based on (6) , we cannot pay
(7) any benefits.
Fill-ins:
-
1.
your/[Claimant name, possessive]
-
-
-
4.
drug addiction/alcoholism/drug addiction and alcoholism
-
-
6.
drug addiction/alcoholism/drug addiction and alcoholism
-
The Decision on (1) Case
Fill-ins:
-
1.
Your/[Claimant name, possessive][ Personalized Denial
Language ]
Specialized stock language explaining DAA materiality is needed for the personalized
explanation. See the paragraph Exhibit 5.
About the Decision
Choice 1: Notice prepared by State DDS:
Doctors and other trained staff looked at this case and made the decision that
(1) health problems are based on (2) . They work for the state but used our rules.
Please remember that there are many types of disability programs, both government
and private, which 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 this case.
Fill-ins:
-
-
2.
drug addiction/alcoholism/drug addiction and alcoholism
Choice 2: Notice prepared by FDDS:
Our doctors and other trained staff looked at this case and made the decision that
(1) health problems are based on
(2) .
Please remember that there are many types of disability programs, both government
and private, which 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 this case.
Fill-in:
-
-
2.
drug addiction/alcoholism/drug addiction and alcoholism
Other Benefits
Based on the applications (1) filed
(2) (3) not entitled to any other benefits besides those (4) may already be getting. In the future, if
(5) (6) (7) may be entitled to benefits, (8) will need to file again.
Fill-ins:
-
-
-
-
-
-
-
-
If You Disagree With The Decision
If you disagree with the decision that (1) health problems are based on (2) , 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 decisions 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 for waiting 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.
Please read the enclosed pamphlets, “Your Right to Question The Decision Made On
Your Social Security Claim” and “Your Right to Question the Decision Made
on Your SSI Claim.” They contain more information about appeals.
Fill-ins:
-
1.
your/[Claimant name, possessive]
-
2.
drug addiction/alcoholism/drug addiction and alcoholism
New Application
You have the right to file a new application at any time, but filing a new application
is not the same as appealing a decision. If you disagree with either of these decisions
and you file a new application for Social Security or SSI instead of appealing,
(1) might lose some benefits, or not qualify for any benefits. Also, we could deny the
new Social Security application using this decision, if the facts and issues are the
same. So, if you disagree with either decision, you should ask for an appeal within
60 days.
Fill-in:
-
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 Social Security benefits to pay toward the
fee. We do not withhold money from SSI benefits to pay your lawyer.
Information About Medicaid (1)
(2)
(3)
Fill-ins:
-
1.
Choice 1: And Other Benefits
Choice 2: NULL
-
-
OPTIONAL PARAGRAPH:
Family Benefits
If (1) a spouse or child we cannot pay them benefits unless (2) entitled to Social Security benefits.
Fill-ins:
-
1.
you have/[claimant name]has
-
If You Have Any Questions
If you have any questions, you may call us toll-free at 1-800-772-1213, or call your
local Social Security office at[FO phone number] . We can answer most questions over
the phone. You can also write or visit any Social Security office. The office that
serves your area is located at:
[Field Office Address
City, ST, ZIP]
If you do call or visit an office, please have this letter with you. It will help
us answer your questions.
[Name]
Regional Commissioner
Enclosures:
SSA Pub. No. 05-10058
SSA Pub. No. 05-11008
EXHIBIT 3 DENIAL OF INITIAL DISABILITY CLAIM - DAA IS MATERIAL - TITLE II (Patterned
on SSA-L443)
Language:
We are writing about (1) claim for Social Security disability benefits. Based on a review of (2) health problems,
(3) not qualify for benefits on this claim. The law says we cannot pay disability benefits
based on (4) . Because
(5) health problems are based on (6) , we cannot pay (7) any benefits.
Fill-ins:
-
1.
your/[Claimant name, possessive]
-
-
-
4.
drug addiction/alcoholism/drug addiction and alcoholism
-
-
6.
drug addiction/alcoholism/drug addiction and alcoholism
-
The Decision on (1) Case
Fill-in:
-
1.
Your/[Claimant name, possessive]
[ Personalized Denial Language]
SEE NOTE IN CONCURRENT NOTICE
About the Decision
Choice 1: Notice prepared by State DDS:
Doctors and other trained staff looked at this case and made the decision that
(1) health problems are based on (2) . They work for the state but used our rules.
Please remember that there are many types of disability programs, both government
and private, which 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 this case.
Fill-ins:
-
-
2.
drug addiction/alcoholism/drug addiction and alcoholism
Choice 2: Notice prepared by FDDS:
Our doctors and other trained staff looked at this case and made the decision that
(1) health problems are based on
(2) .
Please remember that there are many types of disability programs, both government
and private, which 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 this case.
Fill-ins:
-
-
2.
drug addiction/alcoholism/drug addiction and alcoholism
Other Benefits
Based on the applications (1) filed,
(2) (3) not entitled to any other benefits besides those (4) may already be getting. In the future, if
(5) (6) (7) may be entitled to benefits, (8) will need to file again.
Fill-ins:
-
-
-
-
-
-
-
-
If You Disagree With The Decision
If you disagree with the decision that (1) health problems are based on (2) , 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 decisions 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 for waiting 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.
Please read the enclosed pamphlet, “Your Right to Question the Decision Made on Your
Social Security Claim.” It contains more information about the appeal.
Fill-ins:
-
1.
your/[Claimant name, possessive]
-
2.
drug addiction/alcoholism/drug addiction and alcoholism
New Application
You have the right to file a new application at any time, but filing a new application
is not the same as appealing this decision. If you disagree with this decision and
you file a new application instead of appealing:
-
•
(1) might lose some benefits, or not qualify for any benefits, and
-
•
we could deny the new application using this decision, if the facts and issues are
the same.
So, if you disagree with this decision, you should ask for an appeal within 60 days.
Fill-in:
-
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 Social Security benefits to pay toward the
fee.
OPTIONAL PARAGRAPH:
Family Benefits
If (1) a spouse or child we cannot pay them benefits unless (2) entitled to Social Security benefits.
Fill-ins:
-
1.
you have/[claimant name]has
-
If You Have Any Questions
If you have any questions, you may call us toll-free at 1-800-772-1213, or call your
local Social Security office at[FO phone number] . We can answer most questions over
the phone. You can also write or visit any Social Security office. The office that
serves your area is located at:
[Field Office Address
City, ST, ZIP]
If you do call or visit an office, please have this letter with you. It will help
us answer your questions.
[Name]
Regional Commissioner
Enclosure:
SSA Pub. No. 05-10058
EXHIBIT 4 DENIAL OF INITIAL DISABILITY CLAIM - DAA IS MATERIAL - TITLE XVI
(Patterned on SSA-L444)
Language:
We are writing about (1) claim for Supplemental Security Income (SSI) payments. Based on a review of (2) health problems, (3) not qualify for benefits on this claim. The law says we cannot pay SSI disability
benefits based on (4) . Because (5) health problems are based on
(6) , we cannot pay (7) any benefits.
Fill-ins:
-
1.
your/[Claimant name, possessive]
-
-
-
4.
drug addiction/alcoholism/drug addiction and alcoholism
-
-
6.
drug addiction/alcoholism/drug addiction and alcoholism
-
The Decision on (1) Case
Fill-in:
-
1.
Your/[Claimant name, possessive]
[Personalized Denial Language]
SEE NOTE IN CONCURRENT NOTICE
About the Decision
Choice 1: Notice prepared by State DDS:
Doctors and other trained staff looked at this case and made the decision that
(1) health problems are based on (2) . They work for the state but used our rules.
Please remember that there are many types of disability programs, both government
and private, which 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 this case.
Fill-ins:
-
-
2.
drug addiction/alcoholism/drug addiction and alcoholism
Choice 2: Notice prepared by FDDS:
Our doctors and other trained staff looked at this case and made the decision that
(1) health problems are based on
(2) .
Please remember that there are many types of disability programs, both government
and private, which 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 this case.
Fill-ins:
-
-
2.
drug addiction/alcoholism/drug addiction and alcoholism
OPTIONAL PARAGRAPH:
The following paragraph will be used when the field office takes an SSI application
and determines the individual is not entitled to any or additional title II benefits.
As a result the FO does not take a supplemental title II application, but instead
alerts the DDS to use this paragraph. It is patterned after paragraph 1598. That paragraph
cannot be used in this letter as it stresses that case review is the only appeal available
for title II. As this is also true for title XVI in these cases, the emphasis is unnecessary
and confusing.
Information about Social Security Benefits
The application you filed for SSI was also a claim for Social Security benefits. We
looked into this, and decided (1) can't get any Social Security benefits (2) . If you disagree with this decision, you have the right to appeal. The appeal is
described in this letter.
Fill-ins:
-
-
2.
except the benefit you are already getting/except the benefit she is already getting/except
the benefit he is already getting/Null
If You Disagree With The Decision
If you disagree with the decision that (1) health problems are based on (2) , 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 decisions 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 for waiting 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.
Please read the enclosed pamphlet, “Your Right to Question the Decision Made on Your
SSI Claim.” It contains more information about the appeal.
Fill-ins:
-
1.
your/[Claimant name, possessive]
-
2.
drug addiction/alcoholism/drug addiction and alcoholism
How the Appeal Works
You have the right to review the facts in your case. You can give us more facts to
add to your file. Then we will decide your case again. You will not meet the person
who will decide your case.
New Application
You have the right to file a new application at any time, but filing a new application
is not the same as appealing this decision. If you disagree with this decision and
you file a new application instead of appealing, (1) 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.
Fill-in:
-
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.
Information About Medicaid (1)
(2)
(3)
Fill-ins:
-
1.
Choice 1 - And Other Benefits
Choice 2 - NULL
-
-
If You Have Any Questions
If you have any questions, you may call us toll-free at 1-800-772-1213, or call your
local Social Security office at[FO phone number] . We can answer most questions over
the phone. You can also write or visit any Social Security office. The office that
serves your area is located at:
[Field Office Address
City, ST, ZIP]
If you do call or visit an office, please have this letter with you. It will help
us answer your questions.
[Name]
Regional Commissioner
Enclosure:
SSA Pub. No. 05-11008
EXHIBIT 5 DECISION PARAGRAPH FOR PDN - DENIAL - DAA IS MATERIAL
We reviewed the facts in (1) case and decided that
(2) a contributing factor material to a finding of disability. This means (3) would not be disabled if
(4) stopped using (5) . Therefore we cannot consider (6) disabled under the law.
Fill-ins:
-
-
2.
drug addiction is/alcoholism is/drug addiction and alcoholism are
-
-
-
5.
drugs/alcohol/drugs and alcohol
-
EXHIBIT 6 SAMPLE NOTICE - Title XVI DENIAL - DAA IS MATERIAL (Not according to
Notice Standards)
Social Security Administration
Supplemental Security Income
Notice of Disapproved Claim
Date: May 22, 1996
Claim Number: 123-45-6789D
Addressee Name
Street Address
City, St 00000
We are writing about your claim for Supplemental Security Income (SSI) payments. Based
on a review of your health problems, you do not qualify for benefits on this claim.
The law says we cannot pay SSI disability benefits based on drug addiction. Because
drug addiction is a contributing factor material to your disability, we cannot pay
you any benefits.
The Decision on Your Case
We used the following reports to decide your case.
Medical records from Creek Medical Center for December 23, l995 through March 4, l996;
Dr. John N. Nee's report dated March 28, l996; and
Dr. Jack C. Lemon's report dated April 7, l996.
We reviewed the facts in your case and decided that drug addiction is a contributing
factor material to a finding of disability. This means you would not be disabled if
you stopped using drugs. Therefore, we cannot consider you disabled under the law.
You said that you are unable to work because (dictated text)xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxx.
The medical information shows(dictated text) xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
Enclosure:
SSA Pub. No. 05-11008
See Next Page
123-00-6789D
Page 2 of 4
About the Decision
Doctors and other trained staff looked at this case and made the decision that your
health problems are based on drug addiction. They work for the state but used our
rules.
Please remember that there are many types of disability programs, both government
and private, which 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 this case.
Information About Social Security Benefits
The application you filed for SSI was also a claim for Social Security benefits. We
looked into this, and decided you can't get any Social Security benefits. If you disagree
with this decision, you have the right to appeal. The appeal is described in this
letter.
If You Disagree With The Decision
If you disagree with the decision that your health problems are based on drug addiction,
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 for waiting 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.
Please read the enclosed pamphlet, “Your Right to Question the Decision Made on Your
SSI Claim.” It contains more information about the appeal.
123-45-6789DI
Page 3 of 4
How the Appeal Works
You have the right to review the facts in your case. You can give us more facts to
add to your file. Then we will decide your case again. You will not meet the person
who will decide your case.
New Application
You have the right to file a new application at any time, but filing a new application
is not the same as appealing this decision. If you disagree with this decision and
you file a new application 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.
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.
Information About Medicaid
Since you are not receiving SSI payments, you cannot get Medicaid based on SSI. Usually,
people who live in Texas get Medicaid only if they receive SSI payments or Aid to
Families with Dependent Children. However, Texas does offer Medicaid to others, such
as:
-
•
children with low incomes,
-
-
•
people in nursing homes, and
-
•
people who have Medicare Part A and meet certain income and resource rules.
Please contact the Texas Department of Human Services if you have any questions about
their Medicaid program.
123-45-6789DI
Page 4 of 4
If You Have Any Questions
If you have any questions, you may call us toll-free at 1-800-772-1213, or call your
local Social Security office at 1-333-123-4567. We can answer most questions over
the phone. You can also write or visit any Social Security office. The office that
serves your area is located at:
123 Elm Street
Oak, TX 12345
If you do call or visit an office, please have this letter with you. It will help
us answer your questions.
[Name]
Regional Commissioner
EXHIBIT 7 Reconsideration Disability Denial - DAA is Material - Concurrent Title II
- Title XVI
Language:
You asked us to take another look at (1) claims for Social Security and Supplemental Security Income (SSI) disability benefits.
Someone who did not make the first decision reviewed (2) case, including any new facts we received. Based on this review, we found that our
first decision was correct. The law says we cannot pay disability benefits based on
(3) . Because (4) health problems are based on
(5) , we cannot pay (6) any benefits.
Fill-ins:
-
1.
your/[Claimant name, possessive]
-
2.
your/[Claimant name, possessive]
-
3.
drug addiction/alcoholism/drug addiction and alcoholism
-
-
5.
drug addiction/alcoholism/drug addiction and alcoholism
-
The Decisions on (1) Case
(2)
Fill-ins:
-
1.
Your/[Claimant name, possessive]
-
2.
[Personalized Denial Language]
[Including decision paragraph: Exhibit 1D (cleared for initial disability denials)]
We reviewed the facts in (1) case and decided that
(2) a contributing factor material to a finding of disability. This means (3) would not be disabled if
(4) stopped using (5) . Therefore, we cannot consider (6) disabled under the law.
Fill-ins:
-
-
2.
drug addiction is/alcoholism is/drug addiction and alcoholism are
-
-
-
5.
drugs/alcohol/drugs and alcohol
-
About the Decisions
Please remember that there are many types of disability programs, both government
and private, which 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 this case.
Information About Medicaid (1)
Fill-ins:
-
OPTIONAL PARAGRAPH:
MDC010 is an optional paragraph. While it will be used in most cases, it is possible
that another claim could be unadjudicated when the decisions have been made on the
title II and title XVI disability claims.
Based on the applications (1) filed,
(2) (3) not entitled to any other Social Security or SSI benefits besides those (4) may already be getting. In the future, if (5) (6) (7) may be entitled to benefits, (8) will need to file again.
(9)
(10)
Fill-ins:
-
-
-
-
-
-
-
-
-
-
10.
Choice 1: SAS001: (Paragraph 1311 from NL 00804.190)
Choice 2: NULL
If You Disagree With The Decisions
If you disagree with the decision that (1) health problems are based on (2) , 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 consider 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 get this letter. We assume you got this letter
5 days after the date on it unless you show 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.
Fill-ins:
-
-
2.
drug addiction/alcoholism/drug addiction and alcoholism
How The Hearing Process Works
The ALJ will mail you a letter at least 20 days before the hearing to tell you its
date, time and place. The letter will explain the law in your case and tell you what
has to be decided. Since the ALJ will review all the facts in your case, it is important
that you give us any new facts as soon as you can.
The hearing is your chance to tell the ALJ why you disagree with the decisions in
your case. You can give the ALJ new evidence and bring people to testify for you.
The ALJ also can require people to bring important papers to your hearing and give
facts about your case. You can question these people at your hearing.
Please read the enclosed pamphlet “Your Right To An Administrative Law Judge Hearing
And Appeals Council Review Of Your Social Security Case.” It has more information about the hearing.
It Is Important To Go To The Hearing
It is very important that you go to the hearing. If for any reason you can't go, contact
the ALJ as soon as possible before the hearing and explain why. The ALJ will reschedule
the hearing if you have a good reason.
If you don't go to the hearing and don't have a good reason for not going, the ALJ
may dismiss your request for a hearing.
New Application
You have the right to file a new application at any time, but filing a new application
is not the same as appealing a decision. If you disagree with either of these decisions
and you file a new application for Social Security or SSI instead of appealing,
(1) might lose some benefits, or not qualify for any benefits. Also, we could deny the
new Social Security application using this decision, if the facts and issues are the
same. So, if you disagree with either decision, you should ask for an appeal within
60 days.
Fill-in:
-
If You Want Help With Your Hearing
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 Social Security benefits to pay toward the
fee. We do not withhold money from SSI benefits to pay your lawyer.
If You Have Any Questions
If you have any questions, you may call us toll-free at 1-800-772-1213, or call your
local Social Security office at[FO phone number] . We can answer most questions over
the phone. You can also write or visit any Social Security office. The office that
serves your area is located at:
[Field Office Address
City, ST, ZIP]
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.
[Name]
Regional Commissioner
[Show at bottom of first page of notice]
Enclosure:
SSA Pub. No. 70-10281
EXHIBIT 8 Reconsideration Disability Denial - DAA Is Material - Title II
Language:
You asked us to take another look at (1) claim for Social Security disability benefits. Someone who did not make the first
decision reviewed (2) case, including any new facts we received. Based on this review, we found that our
first decision was correct. The law says we cannot pay disability benefits based on
(3) . Because (4) health problems are based on (5) , we cannot pay
(6) any benefits.
Fill-ins:
-
1.
your/[Claimant name, possessive]
-
2.
your/[Claimant name, possessive]
-
3.
drug addiction/alcoholism/drug addiction and alcoholism
-
-
5.
drug addiction/alcoholism/drug addiction and alcoholism
-
The Decision on (1) Case
(2)
Fill-ins:
-
1.
Your/[Claimant name, possessive]
-
2.
[Personalized Denial Language][Including decision paragraph: (cleared for initial
disability denials) -See Concurrent Notice, above]
About the Decision
Please remember that there are many types of disability programs, both government
and private, which 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 this case.
OPTIONAL PARAGRAPH:
This is an optional paragraph. While it will be used in most cases, it is possible
that another claim could be unadjudicated when the decision has been made on the title
II disability claim.
Other Benefits
Based on the application (1) filed,
(2) (3) not entitled to any other Social Security benefits besides those (4) may already be getting. In the future, if
(5) (6) (7) may be entitled to benefits, (8)
will need to file again.
Fill-ins:
-
-
-
-
-
-
-
-
If You Disagree With The Decision
If you disagree with the decision that (1) health problems are based on (2) , 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 consider 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 get this letter. We assume you got this letter
5 days after the date on it unless you show 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.
Please read the enclosed pamphlet, “Your Right to An Administrative Law Judge
Hearing and Appeals Council Review of Your Social Security Case.” It contains more information about the hearing.
Fill-ins:
-
-
2.
drug addiction/alcoholism/drug addiction and alcoholism
New Application
You have the right to file a new application at any time, but filing a new application
is not the same as appealing this decision. If you disagree with this decision and
you file a new application instead of appealing:
-
•
(1) might lose some benefits, or not qualify for any benefits, and
-
•
we could deny the new application using this decision, if the facts and issues are
the same.
So, if you disagree with this decision, you should ask for an appeal within 60 days.
Fill-in:
-
If You Want Help With Your Hearing
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 Social Security benefits to pay toward the
fee.
If You Have Any Questions
If you have any questions, you may call us toll-free at 1-800-772-1213, or call your
local Social Security office at[FO phone number] . We can answer most questions over
the phone. You can also write or visit any Social Security office. The office that
serves your area is located at:
[Field Office Address
City, ST, ZIP]
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.
[Name]
Regional Commissioner
[Show at bottom of first page of notice]
Enclosure:
SSA Pub. No. 70-10281
EXHIBIT 9 Reconsideration Disability Denial - DAA Is Material - Title XVI
Language:
You asked us to take another look at (1) claim for Supplemental Security Income (SSI) payments. Someone who did not make the
first decision reviewed (2) case, including any new facts we received. Based on this review, we found that our
first decision was correct. The law says we cannot pay disability benefits based on
(3) . Because
(4) health problems are based on (5) , we cannot pay (6) any benefits.
Fill-ins:
-
1.
your/[Claimant name, possessive]
-
2.
your/[Claimant name, possessive]
-
3.
drug addiction/alcoholism/drug addiction and alcoholism
-
-
5.
drug addiction/alcoholism/drug addiction and alcoholism
-
The Decision on (1) Case
(2)
Fill-ins:
-
1.
Your/[Claimant name, possessive]
-
2.
[Personalized Denial Language]
[Including decision paragraph: (cleared for initial disability denials) - See Concurrent
Notice, above]
About the Decision
Please remember that there are many types of disability programs, both government
and private, which 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 this case.
OPTIONAL PARAGRAPH:
The following paragraph will be used when the field office takes an SSI application
and determines the individual is not entitled to any or additional title II benefits.
As a result, the FO does not take a supplemental title II application, but alerts
the DDS to use this paragraph. It is patterned after paragraph 1598.
Information about Social Security Benefits
The application you filed for SSI was also a claim for Social Security benefits. We
looked into this, and decided (1) can't get any Social Security benefits (2) . If you disagree with this decision, you have the right to appeal. The appeal is
described in this letter.
Fill-ins:
-
-
2.
except the benefit you are already getting/except the benefit she is already getting/except
the benefit he is already getting/NULL
Information About Medicaid (1)
(2)
(3)
Fill-ins:
-
-
2.
Choice 1 - MDC012
Choice 2 - MDC013
Choice 3 -MDC014
Choice 4 - MDC016
-
3.
Choice 1 - SAS001
Choice 2 - NULL
If You Disagree With The Decision
If you disagree with the decision that (1) health problems are based on (2) , 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 consider 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 get this letter. We assume you got this letter
5 days after the date on it unless you show 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.
Fill-ins:
-
-
2.
drug addiction/alcoholism/drug addiction and alcoholism
How The Hearing Process Works
The ALJ will mail you a letter at least 20 days before the hearing to tell you its
date, time and place. The letter will explain the law in your case and tell you what
has to be decided. Since the ALJ will review all the facts in your case, it is important
that you give us any new facts as soon as you can.
The hearing is your chance to tell the ALJ why you disagree with the decision in your
case. You can give the ALJ new evidence and bring people to testify for you. The ALJ
also can require people to bring important papers to your hearing and give facts about
your case. You can question these people at your hearing.
Please read the enclosed pamphlet “Your Right To An Administrative Law Judge Hearing
And Appeals Council Review Of Your Social Security Case.” It has more information about the hearing.
It Is Important To Go To The Hearing
It is very important that you go to the hearing. If for any reason you can't go, contact
the ALJ as soon as possible before the hearing and explain why. The ALJ will reschedule
the hearing if you have a good reason.
If you don't go to the hearing and don't have a good reason for not going, the ALJ
may dismiss your request for a hearing.
New Application
You have the right to file a new application at any time, but filing a new application
is not the same as appealing this decision. If you disagree with this decision and
you file a new application instead of appealing, (1) 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.
Fill-in:
-
If You Want Help With Your Hearing
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.
If You Have Any Questions
If you have any questions, you may call us toll-free at 1-800-772-1213, or call your
local Social Security office at[FO phone number] . We can answer most questions over
the phone. You can also write or visit any Social Security office. The office that
serves your area is located at:
[Field Office Address
City, ST, ZIP]
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.
[Name]
Regional Commissioner
[Show at bottom of first page of notice]
Enclosure:
SSA Pub. No. 70-10281
EXHIBIT 10 REMAINDER OF NOTICE - TITLE II
If You Disagree With The Decision
If you disagree with the 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 consider 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 get this letter. We assume you got this letter
5 days after the date on it unless you show 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.
Please read the enclosed pamphlet, “Your Right to An Administrative Law Judge
Hearing and Appeals Council Review of Your Social Security Case.” It contains more information about the hearing.
If You Want Help With Your Hearing
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 Social Security benefits to pay toward the
fee.
If You Have Any Questions
[Appropriate referral paragraph]
Enclosure:
SSA Pub. No. 70-10281
Referral Paragraphs:
UNDER THE CAPTION:
If You Have Any Questions
Choice 1: USE: Notice prepared by DDS
If you have any questions, call us toll-free at 1-800-772-1213 or call your local
Social Security office at (TRIDE fill-in). We can answer most questions over the phone.
You can also write or visit any Social Security office. The office that serves your
area is located at:
Field Office Address
City ST ZIP
If you do call or visit an office, please have this letter with you. It will help
us answer your questions.
Choice 2: USE: Notice prepared by FO
If you have any questions, you may call, write, or visit any Social Security office.
If you call or visit our office, please have this letter with you and ask for (name).
The telephone number is shown at the top of this letter.
-
A.
Title II - Unfavorable, DAA Material
Title XVI - Unfavorable (DHO hearing declined), DAA Material
Concurrent - Unfavorable (DHO hearing declined), DAA Material
Language
You asked us to take another look at (1) (2) case. Someone who did not see
(3) case before reviewed (4) case, including any new facts we received, and found that our decision was correct.
We have decided that (5) a contributing factor material to (6) disability. The law says that we cannot pay disability benefits based on (7) . (8)
Fill-ins:
-
1.
Choice 1: your
Choice 2: Claimant name, possessive
-
2.
Choice 1: Social Security disability
Choice 2: Supplemental Security Income (SSI) disability
Choice 3: Social Security disability and Supplemental Security Income (SSI) disability
-
3.
Choice 1: your
Choice 2: his
Choice 3: her
-
4.
Choice 1: your
Choice 2: his
Choice 3: her
-
5.
Choice 1: drug addiction is
Choice 2: alcoholism is
Choice 3: drug addiction and alcoholism are
-
6.
Choice 1: your
Choice 2: his
Choice 3: her
-
7.
Choice 1: drug addiction
Choice 2: alcoholism
Choice 3: drug addiction and alcoholism
-
8.
Choice 1: USE: Benefits being paid (notice sent before 1/1/97, eligible for benefits)
This means that (A) (B) will end January 1, 1997.
Fill-ins:
-
A.
Choice 1: your
Choice 2: his
Choice 3: her
-
B.
Choice 1: disability benefits
Choice 2: SSI benefits
Choice 3: Social Security disability and SSI benefits
Choice 2: USE: Benefits being paid (notice sent after 1/1/97, but Goldberg/Kelly benefits
elected)
This means that (A) eligibility for SSI benefits ended effective January 1, 1997.
We may be in touch with you later about any payments we previously made.
Fill-in:
-
A.
Choice 1: your
Choice 2: his
Choice 3: her
Choice 3: USE: Benefits ended (notice sent after 1/1/97)
This means that (A) (B) (C) ended effective January 1, 1997.
Fill-ins:
-
A.
Choice 1: your
Choice 2: his
Choice 3: her
-
B.
Choice 1: USE: TXVI or Concurrent
eligibility for
Choice 2: USE: TII
entitlement to
-
C.
Choice 1: disability benefits
Choice 2: SSI benefits
Choice 3: Social Security disability and SSI benefits
Title II - Unfavorable, not disabled
Title XVI - Unfavorable (DHO hearing declined), Not disabled
Concurrent - Unfavorable (DHO hearing declined), Not disabled
Language:
You asked us to take another look at (1) (2) case. Someone who did not see
(3) case before reviewed (4) case, including any new facts we received. After reviewing all the information carefully,
we cannot find that (5) disability rules.
(6)
Fill-ins:
-
1.
Choice 1: your
Choice 2: Claimant name, possessive
-
2.
Choice 1: Social Security disability
Choice 2: Supplemental Security Income (SSI) disability
Choice 3: Social Security disability and Supplemental Security Income (SSI) disability
-
3.
Choice 1: your
Choice 2: his
Choice 3: her
-
4.
Choice 1: your
Choice 2: his
Choice 3: her
-
5.
Choice 1: you meet
Choice 2: he meets
Choice 3: she meets
-
6.
Choice 1: USE: Benefits being paid (notice sent before 1/1/97, eligible for benefits)
This means that (A) (B) will end effective January 1, 1997.
Fill-ins:
-
A.
Choice 1: your
Choice 2: his
Choice 3: her
-
B.
Choice 1: disability benefits
Choice 2: SSI benefits
Choice 3: Social Security disability and SSI benefits
Choice 2: USE: Benefits being paid (notice sent after 1/1/97, but Goldberg/Kelly benefits
elected)
This means that (A) eligibility for SSI benefits ended effective January 1, 1997.
We may be in touch with you later about any payments we previously made.*
*This is paragraph #1438 in NL 00804.210. It is used in PE situations when we may have to send an overpayment notice later.
Fill-in:
-
A.
Choice 1: your
Choice 2: his
Choice 3: her
Choice 3: USE: Benefits ended (notice sent after 1/1/97)
This means that (A) (B) (C) ended effective January 1, 1997.
Fill-ins:
-
A.
Choice 1: your
Choice 2: his
Choice 3: her
-
B.
Choice 1: USE: TXVI or Concurrent
eligibility for
Choice 2: USE: TII
entitlement to
-
C.
Choice 1: disability benefits
Choice 2: SSI benefits
Choice 3: Social Security disability and SSI benefits
Title II, Title XVI, caption:
The Decision on (1) Case
Fill-in:
-
1.
Choice 1: your
Choice 2: Claimant name, possessive
Concurrent, caption:
The Decision on (1) Case
Fill-in:
-
1.
Choice 1: your
Choice 2: Claimant name, possessive
Title II, Title XVI, Concurrent: (2)
Fill-in:
-
2.
[Personalized Case Language]
Title II, Title XVI, caption:
About The Decision
Concurrent, caption:
About The Decisions
-
Choice 1: USE: Medical determination - case prepared by DDS
Doctors and other trained staff looked at this case and made this decision.
They work for the state but use our rules.
Choice 2: USE: Medical determination - case prepared by FDDS
Our doctors and other trained staff looked at this case and made this decision.
If You Disagree With The Decision
If you disagree with the 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 consider 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 get this letter. We assume you got this letter
5 days after the date on it unless you show 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.
Please read the enclosed pamphlet “Your Right To An Administrative Law Judge
Hearing And Appeals Council Review of Your Social Security Case.” It has more information about the hearing.
If You Want Help With Your Hearing
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 hearing.
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 Social Security benefits to pay toward the
fee.
If You Disagree With The Decision
If you disagree with the 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 consider any new facts you
have.
-
•
You have 60 days to ask for a hearing.
-
•
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 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.
How The Hearing Process Works
The ALJ will mail you a letter at least 20 days before the hearing to tell you its
date, time and place. The letter will explain the law in your case and tell you what
has to be decided. Since the ALJ will review all the facts in your case, it is important
that you give us any new facts as soon as you can.
The hearing is your chance to tell the ALJ why you disagree with the decision in your
case. You can give the ALJ new evidence and bring people to testify for you. Tha ALJ
also can require people to bring important papers to your hearing and give facts about
your case. You can question these people at your hearing.
Please read the enclosed pamphlet “Your Right To An Administrative Law Judge
Hearing And Appeals Council Review of Your Social Security Case.” It has more information about the hearing.
It Is Important To Go To The Hearing
It is very important that you go to the hearing. If for any reason you can't go, contact
the ALJ as soon as possible before the hearing and explain why. The ALJ will reschedule
the hearing if you have a good reason.
If you don't go to the hearing and don't have a good reason for not going, the ALJ
may dismiss your request for a hearing.
If You Want Help With Your Hearing
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 hearing.
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.
If You Disagree With The Decisions
If you disagree with the decisions, 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 consider any new facts you
have.
-
•
You have 60 days to ask for a hearing.
-
•
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 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.
How The Hearing Process Works
The ALJ will mail you a letter at least 20 days before the hearing to tell you its
date, time and place. The letter will explain the law in your case and tell you what
has to be decided. Since the ALJ will review all the facts in your case, it is important
that you give us any new facts as soon as you can.
The hearing is your chance to tell the ALJ why you disagree with the decision in your
case. You can give the ALJ new evidence and bring people to testify for you. Tha ALJ
also can require people to bring important papers to your hearing and give facts about
your case. You can question these people at your hearing.
Please read the enclosed pamphlet “Your Right To An Administrative Law Judge
Hearing And Appeals Council Review of Your Social Security Case.” It has more information about the hearing.
It Is Important To Go To The Hearing
It is very important that you go to the hearing. If for any reason you can't go, contact
the ALJ as soon as possible before the hearing and explain why. The ALJ will reschedule
the hearing if you have a good reason.
If you don't go to the hearing and don't have a good reason for not going, the ALJ
may dismiss your request for a hearing.
If You Want Help With Your Hearing
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 hearing.
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 Social Security benefits to pay toward the
fee. We do not withhold money from SSI benefits to pay your lawyer.
Title II, Title XVI, Concurrent:
If You Have Any Questions
If you have any questions, call us toll-free at 1-800-772-1213 or call your local
Social Security office at (TRIDE fill-in). We can answer most questions over the phone.
You can also write or visit any Social Security office. The office that serves your
area is located at:
Field Office Address
City ST ZIP
If you do call or visit an office, please have this letter with you. It will help
us answer your questions.
Title II, Title XVI, Concurrent:
Enclosure:
SSA Pub. No. 70-10281