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    Ha 501

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    The document is a request form for a hearing before an administrative law judge from the Social Security Administration's Office of Disability Adjudication and Review. It provides information about the claimant and their reason for disagreeing with SSA's determination. It also allows the claimant to indicate whether they will submit additional evidence or wish to appear at a hearing. Upon completion, the form is to be submitted to the claimant's local SSA office.

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    Ha 501

    Uploaded by

    john
    1K views2 pages
    The document is a request form for a hearing before an administrative law judge from the Social Security Administration's Office of Disability Adjudication and Review. It provides information about the claimant and their reason for disagreeing with SSA's determination. It also allows the claimant to indicate whether they will submit additional evidence or wish to appear at a hearing. Upon completion, the form is to be submitted to the claimant's local SSA office.

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    Hearing Request

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    ha-501

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    The document is a request form for a hearing before an administrative law judge from the Social Security Administration's Office of Disability Adjudication and Review. It provides information about the claimant and their reason for disagreeing with SSA's determination. It also allows the claimant to indicate whether they will submit additional evidence or wish to appear at a hearing. Upon completion, the form is to be submitted to the claimant's local SSA office.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1K views2 pages

    Ha 501

    Uploaded by

    john
    The document is a request form for a hearing before an administrative law judge from the Social Security Administration's Office of Disability Adjudication and Review. It provides information about the claimant and their reason for disagreeing with SSA's determination. It also allows the claimant to indicate whether they will submit additional evidence or wish to appear at a hearing. Upon completion, the form is to be submitted to the claimant's local SSA office.

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    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 6. Do not complete if the appeal is a Medicare
    issue. Otherwise, check one of the blocks
    Name and source of additional evidence, if not included.
    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
    Submit your evidence to the hearing office within 10 days. Your servicing the evidence in my case. (Complete
    Social Security office will provide the hearing office's address. Attach an Waiver Form HA-4608)
    additional sheet if you need more space.
    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) TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS
    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)

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