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When navigating the process of appealing a decision regarding Social Security benefits, the Request For Hearing form serves as a crucial tool for claimants. This form enables individuals to formally request a hearing before an Administrative Law Judge (ALJ) when they disagree with a determination made by the Social Security Administration (SSA). It's essential for the claimant to fill out personal information accurately, including their name, Social Security number, and any claim numbers associated with their case. The form provides the opportunity for claimants to state the reasons for their disagreement and indicates whether they have additional evidence to submit, which must be provided within a specified time frame. Notably, claimants can choose to appear at the hearing in person or request that a decision be made based solely on the evidence submitted. Legal representation is also permitted, with guidelines to appoint a representative if desired. Finally, by submitting this form, individuals enter a process where they will receive timely notifications regarding their hearing, ensuring transparency and support as they seek to resolve their claims.

Request For Hearing Example

TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS

SOCIAL SECURITY ADMINISTRATION

Form Approved

OFFICE OF DISABILITY ADJUDICATION AND REVIEW

OMB No. 0960-0269

REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE

See Privacy

(Take or mail the completed original to your local Social Security office, the Veterans Affairs Regional

Act Notice

Office in Manila or any U.S. Foreign Service post and keep a copy for your records)

 

1. Claimant Name

2. Claimant SSN

3. Claim Number, if different

 

4. I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE. I disagree with the determination because:

An Administrative Law Judge of the Social Security Administration's Office of Disability Adjudication and Review or the Department of Health and Human Services will be appointed to conduct the hearing or other proceedings in your case. You will receive notice of the time and place of a hearing at least 20 days before the date set for a hearing.

5. I have additional evidence to submit.

Yes

No

Name and source of additional evidence, if not included.

Submit your evidence to the hearing office within 10 days. Your servicing Social Security office will provide the hearing office's address. Attach an additional sheet if you need more space.

6.Do not complete if the appeal is a Medicare issue. Otherwise, check one of the blocks

I wish to appear at a hearing.

I do not wish to appear at a hearing and I request that a decision be made based on the evidence in my case. (Complete Waiver Form HA-4608)

Representation: You have a right to be represented at the hearing. If you are not represented, your Social Security office will give you a list of legal referral and service organizations. If you are represented, complete and submit form SSA-1696 (Appointment of Representative) unless you are appealing a Medicare issue.

7. CLAIMANT SIGNATURE (OPTIONAL)

 

DATE

8. NAME OF REPRESENTATIVE (if any)

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESIDENCE ADDRESS

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

STATE

 

ZIP CODE

CITY

 

 

STATE

 

 

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

 

FAX NUMBER

TELEPHONE NUMBER

 

FAX NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO BE COMPLETED BY SOCIAL

SECURITY ADMINISTRATION- ACKNOWLEDGMENT OF REQUEST FOR HEARING

9. Request received on

 

 

 

 

 

 

 

by:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Date)

 

 

 

 

 

 

(Print Name)

 

 

(Title)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Address)

 

 

 

 

 

 

 

(Servicing FO Code)

 

 

(PC Code)

10.

Was the request for hearing received within 65 days of the reconsidered determination?

Yes

No

 

 

If no, attach claimant's explanation for delay and supporting documents if any.

 

 

 

 

 

 

11.

If claimant is not represented, was a list of legal referral

 

 

15. Check all claim types that apply:

 

 

 

 

 

service organizations provided?

Yes

 

No

 

 

 

Retirement and Survivors Insurance Only

(RSI)

12.

Interpreter needed

 

Yes

No

 

 

 

 

 

 

 

Title II Disability - Worker or child only

(DIWC)

Language (including sign language):

 

 

 

 

 

 

 

Title II Disability - Widow(er) only

 

 

 

(DIWW)

13.

Check one:

Initial Entitlement Case

 

 

 

 

 

 

 

Title XVI (SSI) Aged only

 

 

 

 

 

(SSIA)

 

Disability Cessation Case or

Other Postentitlement Case

Title XVI Blind only

 

 

 

 

 

(SSIB)

14.

HO COPY SENT TO:

 

 

 

HO on

 

 

 

 

Title XVI Disability only

 

 

 

 

 

(SSID)

Claims Folder (CF) Attached:

Title (T) II;

 

 

T

XVI;

 

 

 

Title XVI/Title II Concurrent Aged Claim

(SSAC)

T VIII; T XVIII;

T II CF held in FO

Electronic Folder

Title XVI/Title II Concurrent Blind

 

 

 

(SSBC)

CF requested

T II;

 

T XVI;

T VIII;

 

T XVIII

 

 

 

Title XVI/Title II Concurrent Disability

 

 

 

(SSDC)

(Copy of email or phone report attached)

 

 

 

 

 

 

 

Title XVIII Hospital/Supplementary Insurance

(HI/SMI)

16.

CF COPY SENT TO:

 

 

 

HO on

 

 

 

 

Title VIII Only Special Veterans Benefits

(SVB)

 

CF Attached:

Title (T) II;

T XVI;

T XVIII

 

 

 

Title VIII/Title XVI

 

 

 

 

 

(SVB/SSI)

 

Other Attached:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other - Specify:

 

 

 

 

 

 

Form HA-501-U5 (01-2015) ef (01-2015)

Use 08-2012 Edition Until Stock is Exhausted

PRIVACY ACT STATEMENT

Request for Hearing by Administrative Law Judge

Sections 205(a) (42 U.S.C. 405 (a)), 702 (42 U.S.C. 902), 1631(e) (1) (A), and; (B) (42 U.S.C. 1383(e)

(1)(A) and (B)), 1839(i) (42 U.S.C. 1395r), 1869(b) (1), and (c) (42 U.S.C. 1395ff) of the Social Security Act, as amended, authorize us to collect this information. We will use the information you provide to continue processing your claim.

Providing this information is voluntary. However, failing to provide us with all or part of the requested information may prevent us from making an accurate and timely decision on your claim.

We rarely use the information you supply for any purpose other than for determining problems in Social Security programs. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include, but are not limited to the following:

1.To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;

2.To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and the Department of Veterans' Affairs);

3.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and

4.To facilitate statistical research, audit, or investigate activities necessary to assure the integrity of Social Security programs.

We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.

A complete list of routine uses for this information is available in System of Records Notices 60-0089, Claims Folder System and 60-0050, Completed Determination-Continuing Disablility Determinations. These notices, additional information regarding this form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or any local Social Security office.

Paperwork Reduction Act Statement - This information collection meets the requirements of

44 U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL

SECURITY OFFICE. You can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).

You may send comments on our time estimate above to:SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Form HA-501-U5 (01-2015) ef (01-2015)

Form Characteristics

Fact Name Details
Purpose of the Form The Request For Hearing form is used to appeal decisions made by the Social Security Administration regarding disability benefits.
Filing Location The completed form must be submitted to the local Social Security office, or other designated offices like the Veterans Affairs Regional Office in Manila.
Submission Timeline Claimants have 65 days from the reconsideration determination to submit the request for a hearing.
Governing Law This form is governed under various sections of the Social Security Act, including 42 U.S.C. 405(a) and 42 U.S.C. 902.

Guidelines on Utilizing Request For Hearing

Once you have the Request For Hearing form, it’s important to fill it out completely and accurately. After submitting it, a hearing will be scheduled where your case will be reviewed. You'll receive notice of the hearing date and location ahead of time. Follow these steps to ensure your form is ready for submission.

  1. Start by writing your full name in the space provided for Claimant Name.
  2. Next, enter your Social Security Number (SSN).
  3. If you have a different claim number, write that next to Claim Number, otherwise leave it blank.
  4. Indicate your desire for a hearing by checking the box next to I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE.
  5. Explain briefly why you disagree with the previous determination. Keep this clear and to the point.
  6. If you have additional evidence, check Yes. Provide the name and source of this evidence, or check No.
  7. If you are submitting extra evidence, make sure to send it to the hearing office within 10 days. Mention that your Social Security office will provide the address.
  8. Decide whether you want to appear at the hearing or prefer a decision based solely on the submitted evidence. Check the appropriate box.
  9. If you have a representative, provide their name, address, and telephone number in the designated area. If not, you can skip this step.
  10. Sign and date the form in the CLAIMANT SIGNATURE section. This is optional.
  11. If applicable, let your representative complete their name and date as required.
  12. Finally, ensure you keep a copy for your records and send the original to your local Social Security office.

After submitting your completed Request For Hearing form, watch for further communications from the Social Security Administration regarding your hearing. It's vital to stay organized and keep track of all correspondences related to your case.

What You Should Know About This Form

What is the purpose of the Request For Hearing form?

The Request For Hearing form serves as a formal request for individuals to appeal a decision made by the Social Security Administration (SSA) regarding their disability benefits. When a claimant disagrees with the SSA's determination, this form initiates the process to have their case reviewed by an Administrative Law Judge (ALJ). By completing and submitting this form, claimants are indicating their desire for a hearing where they can present additional evidence and explain why they believe the previous decision was incorrect.

How do I submit the Request For Hearing form?

To submit the Request For Hearing form, you should take the completed original form and deliver it to your local SSA office. Alternatively, you can mail it to the Veterans Affairs Regional Office in Manila or any U.S. Foreign Service post. Regardless of the method you choose, be sure to keep a copy for your records. This step ensures that you have a reference should any questions arise about your submission or if further action is needed on your part.

What happens after I submit the Request For Hearing form?

Once you submit the Request For Hearing form, the SSA will process your request. You will receive a notification regarding the time and place of your hearing at least 20 days before it is scheduled. The SSA will appoint an Administrative Law Judge to oversee the hearing, which provides you an opportunity to present further evidence and clarify your case. Additionally, you may bring a representative to assist you during this process, should you choose to do so.

Is there a deadline for submitting additional evidence with the Request For Hearing?

Yes, it is essential to submit any additional evidence you want to be considered at the hearing. You must provide this evidence to the hearing office within 10 days of submitting your Request For Hearing form. The SSA office can provide you with the address of the hearing office to which you should send your documents. Timely submission of your evidence helps ensure that it is reviewed before your hearing, which could significantly impact the outcome of your case.

Common mistakes

Filling out the Request For Hearing form can be a daunting task, and many individuals make mistakes that can lead to delays or complications in their cases. One common mistake occurs when people fail to double-check their personal information, such as the Claimant Name and Social Security Number (SSN). Any discrepancy in this information could cause significant delays in processing, as the Social Security Administration (SSA) may struggle to match the request to the correct case file.

Additionally, many individuals neglect to provide a clear explanation of their disagreement with the prior determination in the section labeled, “I disagree with the determination because:”. A vague or insufficient explanation can weaken the case, potentially leaving the Administrative Law Judge without a clear understanding of the issues at hand. This lack of specificity may result in a less favorable outcome, as judges rely heavily on the clarity of the arguments presented.

Another mistake often seen is the failure to submit additional evidence timely. The form states that any additional evidence must be submitted within 10 days of the hearing request. Missing this deadline can hinder the fact-finding process, which is crucial for establishing the merits of the claim. Therefore, it is vital for applicants to note this requirement and plan accordingly to gather and submit pertinent documents.

Some individuals also overlook the importance of indicating whether they wish to appear at the hearing. If one fails to check the appropriate box—whether for attending the hearing or preferring a decision based on existing evidence—this oversight can lead to confusion and administrative setbacks. Clear communication regarding personal preferences is essential to ensure that appeals are handled efficiently.

Completing the form without considering representation options can be another mistake. Some applicants underestimate the value of having legal representation, especially in complex cases. If individuals choose to be represented, they must complete and submit the Appointment of Representative (SSA-1696) form. Failure to do so might leave them without the necessary legal support during the hearing process.

Lastly, individuals often forget to keep a copy of the completed Request For Hearing form for their records. Retaining a copy provides a reference for future correspondence and ensures that claimants have the necessary information at hand in case any complications arise. This simple step can be invaluable for tracking the progress of one’s case and serves as proof of submission should verification be needed later.

Documents used along the form

When filing a Request For Hearing form, several other forms and documents may also be needed to support the case. These documents help provide additional information, designate representation, and ensure a smooth hearing process.

  • SSA-1696 (Appointment of Representative): This form designates an individual to represent the claimant during the hearing. It is required if the claimant chooses to have representation.
  • HA-4608 (Waiver of Right to Appear): A claimant uses this form to request that the hearing be decided based on submitted evidence without appearing in person.
  • Medical Evidence Documentation: This may include medical records, test results, and treatment history, which substantiate the claim for disability benefits.
  • Work History Report (Form SSA-3369): This report details the claimant's past employment, including job duties and earnings, which helps assess the ability to work.
  • Function Report (Form SSA-3373): This document provides information about how the claimant's condition affects daily activities, including personal care and social interaction.
  • Appeal Documents: These may include any prior denial letters, notices of reconsideration, and any other relevant correspondence with Social Security.
  • Authorization for Release of Information (Form SSA-827): This form allows medical providers to share information with Social Security, ensuring the agency can access necessary medical evidence.
  • Proof of Identity: Acceptable forms of identification, such as a driver's license or Social Security card, may be required to verify the claimant’s identity.
  • Income Verification Documents: These include pay stubs or tax returns that help determine financial eligibility for benefits.

Collecting and preparing these documents is crucial for a successful hearing. They form the foundation of the claimant’s case and provide necessary background information to the Administrative Law Judge.

Similar forms

  • Notice of Appeal: This document allows a claimant to formally challenge a decision made on their Social Security claim. Like the Request for Hearing, it serves as a request for further review of the case, ensuring that claimants can pursue their rights if they disagree with a determination.
  • Request for Reconsideration: This form is used when a claimant wants to ask for a second look at their case before going to a hearing. It shares the purpose of seeking a review, similar to the Request for Hearing, but is typically an earlier step in the appeals process.
  • Form SSA-1696 (Appointment of Representative): Claimants may use this form to authorize someone to represent them in their disability case. While the Request for Hearing outlines a claimant's intent to appeal, the SSA-1696 allows for appointed representation during that process.
  • Waiver Form HA-4608: This form is used if a claimant does not wish to appear at a hearing and prefers that a decision is made based on the existing evidence. Much like the hearing request, it communicates the claimant's wishes regarding the appeal process.
  • Additional Evidence Submission Form: This document is often submitted alongside a hearing request to provide new information. Similar to the Request for Hearing, it emphasizes a claimant's right to enhance their case with new evidence and keeps the appeals process transparent.
  • Social Security Administration Acknowledgment of Request for Hearing: This acknowledgment form confirms the receipt of the hearing request. Like the Request for Hearing, it serves as an important record in the appeals process, ensuring that all parties are aware of the ongoing proceedings.

Dos and Don'ts

When filling out the Request For Hearing form, it's essential to follow specific guidelines to ensure your submission is complete and accurate. Below is a list of helpful dos and don'ts.

  • DO take or send the original form to the Social Security Administration (SSA) and keep a copy for your personal records.
  • DO fill in all required fields, including your name, Social Security Number (SSN), and Claim Number.
  • DO indicate clearly if you wish to appear at the hearing or prefer a decision based on existing evidence.
  • DO submit any additional evidence within 10 days to support your request and include the name and source of that evidence.
  • DO check for any specific instructions regarding your claim type before completing the form.
  • DO consider seeking representation for additional support through the hearing process.
  • DON'T overlook the deadline. Ensure your request is made within the timeframe allowed.
  • DON'T submit the form if your appeal is solely concerning a Medicare issue without following the specific guidelines provided.

Misconceptions

  • Misconception 1: The Request for Hearing form is only for disability claims.
  • This form can be used for various types of claims, including retirement and survivors insurance. It is not exclusively for disability issues.

  • Misconception 2: Completing the form guarantees a hearing.
  • A hearing is not guaranteed simply by submitting this form; a review of the eligibility and circumstances is conducted before a hearing is scheduled.

  • Misconception 3: You must appear in person for a hearing.
  • Claimants have the option to request a decision based on existing evidence, meaning that personal attendance at a hearing is not always necessary.

  • Misconception 4: The completed form does not require a signature.
  • Misconception 5: You have an unlimited amount of time to submit additional evidence.
  • The form specifies that additional evidence should be submitted within ten days of the hearing request, emphasizing the need for timely submissions.

  • Misconception 6: You cannot have legal representation during the hearing process.
  • Claimants have the right to legal representation during the hearing. The Social Security office provides a list of organizations that can assist with representation.

  • Misconception 7: Sending the form to any address will suffice.
  • The form must be sent to the appropriate local Social Security office or designated location as specified, ensuring it reaches the right department for processing.

  • Misconception 8: The form is only for individuals with a completed claim.
  • This request can also be filed regarding reconsidered determinations, not just finalized claims. Thus, individuals in the appeals process can also utilize it.

  • Misconception 9: Submitting the form is the last step in the appeals process.
  • Submitting the Request for Hearing initiates the next step in the appeals process, but it is not the final step, as further communication and information may be required.

  • Misconception 10: There is no need to keep a copy of the form for personal records.
  • It is important to retain a copy of the submitted form for personal records. This serves as proof of the request and aids in tracking the claim's progress.

Key takeaways

Filling out the Request For Hearing form correctly is essential to ensure your hearing is scheduled efficiently. Here are some key takeaways to consider:

  1. Always send the original form to the Social Security Administration (SSA) while keeping a copy for your records.
  2. Include the claimant's name and social security number (SSN) prominently on the form for identification purposes.
  3. Clearly state your reasons for requesting a hearing. Use the space provided to detail the disagreement with the previous determination.
  4. Submit any additional evidence within 10 days of the hearing request. Make sure it's labeled to avoid confusion.
  5. If you choose to appear at the hearing, indicate this clearly on the form. Alternatively, you can request a decision based solely on the evidence submitted.
  6. You have the right to representation during the hearing. If you plan to have a representative, fill out the Appointment of Representative form (SSA-1696).
  7. Double-check the submission deadline. Ensure the request is sent within 65 days of receiving the reconsidered determination to avoid issues.
  8. If you need an interpreter, specify this request on the form and indicate the language required.
  9. Retain a record of the date you submitted your hearing request. This date can be critical for tracking the timeline of your case.
  10. Familiarize yourself with the specific types of claims indicated on the form. This helps in correctly identifying your case type.

By following these recommendations, you can navigate the hearing request process more effectively. It’s advisable to read through all the instructions carefully before submission to avoid any delays in your case.