Request for Hearing By Administrative Law Judge
20 CFR 404.929, 404.933, 416.1429, 416.1433, 42 CFR 405.722, 20 CFR 418.1350
OMB No. 0269
Background
Effective September 2007, a claimant who receives a DDS medical denial notice may appeal SSA’s determination by using the URL provided. The URL provides the link to the Internet Appeal Process which is a two-part process. The first part is completing and submitting the appeal request (i501). The second part of the process is completing and submitting the Appeal Disability Report (i3441) which is cleared under OMB No. 0960‑0144. We are limiting this clearance to the screens the individual will use to request a hearing by an Administrative Law Judge. The clearance for the Appeal Disability Report (i3441) will be done separately.
The claimant who disagrees with SSA’s initial claim for disability will go into the Internet Appeal screen path, complete the questions (which follow the paper appeal form HA-501-U5 (Request for Hearing by Administrative Law Judge)), and submit his/her request for an ALJ hearing. The claimant will receive a confirmation page which includes the exact details of his/her submitted appeal. The confirmation page shows the date and time SSA received the request. The claimant can print and save this page for his/her records.
There are no changes to the HA-501-U5 that OMB cleared on May 3, 2007.
Because the internet is a different medium from the paper forms used for an appeal, it was necessary to make slight changes to show the differences between the Internet Appeals screens and the HA-501-U5. Those differences are shown below.
Wording Differences between Internet Appeal Screen and Form HA-501-U5
There are slight wording differences throughout the Internet Appeals screens. For example, the form states “Do not complete if the appeal is a Medicare issue” and the screen states “Do not complete this question if the appeal is a Medicare issue.”
The first screen “Should You Use This Internet Appeal Process?” provides four mandatory questions that the individual must complete to determine if he/she should use the internet process. Those questions are:
Claimant Name
Claimant Social Security Number
Claimant date of birth
Notice of Decision date (the date on the notice of decision the individual received)
If the individual does not know which date we are referring to, he/she is told to see “What Is My Service Date?
The next screen “About the Request for Hearing by Administrative Law Judge” provides a brief introduction into the internet Request for an ALJ Hearing.
The next screen “How This Internet Appeal Request Works” provides an explanation on completing and submitting the Internet Appeal Request and how to move around in the Internet Appeal Request.
The next screen “Request for Hearing by Administrative Law Judge” begins completion of the HA-501-U5 Request for Hearing by Administrative Law Judge. This screen differs from the form as follows:
In the way additional evidence is addressed. The screen tells the individual to provide the name and address of source of additional evidence in Part 2 “Appeal Disability Report.”
Provides a link to the HA-4608 “Waiver of Your Right To Personal Appearance Before an Administrative Law Judge.”
Asks the question “Do you currently have a representative?” with a “Yes/No” box.
States “If yes, select whether the individual is “completing this form as the Claimant” or “completing this form as the Claimant’s representative.”
This question is similar to the paper form but worded differently due to the difference in the medium. If the individual filing is the claimant, he/she will complete the Representative Information screen and the Submit Request for ALJ Hearing—Claimant screens. If filing as the representative, he/she will complete the Representative Information screen and the Submit Request for ALJ Hearing—Representative screens.
The next screen “Submit Request for Hearing by Administrative Law Judge—Claimant” provides the Penalty of Perjury clause and tells the claimant:
To review this summary to ensure the answers were entered correctly.
If you agree with all your statements, use the Sign and Submit button to send this appeal request to Social Security.
If you disagree with any of your statements, use the Previous Page button to go back to the questions and correct the information.
When you select “Sign Now,” you will be sending your completed application electronically to the Social Security Administration. You will no longer be able to change your information. Please review your information before selecting “Sign Now.”
The next screen “Confirmation for Request for Hearing by Administrative Law Judge—Claimant
Recommends claimant print or save this page for his/her records.
Includes the exact details of the submitted appeal.
Provides instructions on how to print, save, or view the saved file.
Provides the date and time the Request for Hearing by Administrative Law Judge was received by Social Security
Under What You Need To Do tells claimant to
Review this summary to ensure we recorded your statements correctly.
Print and keep this confirmation page for your records.
If you disagree with any of your statements, you should contact us within 10 days after {today’s date} to let us know.
The next screen “Submit Request for Hearing by Administrative Law Judge—Representative” provides the Penalty of Perjury clause and tells the representative the same information as provided in the screen “Submit Request for Hearing by Administrative Law—Claimant”
The next screen “Confirmation for Request for Hearing by Administrative Law Judge—Representative” provides the same information as the screen “Confirmation for Request for Hearing by Administrative Law Judge—Claimant”
| File Type | application/msword |
| File Title | ADDENDUM TO FORM SSA 561 |
| Author | 196328 |
| Last Modified By | 177717 |
| File Modified | 2007-06-15 |
| File Created | 2007-06-11 |