SSA uses Form HA-504 as the claimants'
acknowledgement of receipt for the Notice of Hearing issued by an
administrative law judge (ALJ). The HA-504 establishes the time and
place of the hearing, and reminds claimants to gather evidence in
support of their claim. We are adding a new version of this form to
adhere to our regulatory revisions adding a phone teleconferencing
option (see Addendum for more information). Therefore, SSA has
three versions of this form, the HA-504 (with video
teleconferencing), the HA-504-OP1 (without any teleconferencing),
and the new HA-504-OP2 (with phone teleconferencing). The
difference between the forms relates to the claimant's appearance
for the hearing (in-person, video teleconference, or phone
teleconference). SSA determines which version of the form to use
based on where the claimant lives, and the location of the ALJ and
experts involved in the case. If SSA can conduct the hearing via
teleconferencing, we send the HA-504 and attempt to schedule a
teleconference. We estimate we conduct approximately 20 percent of
all hearings via teleconferencing (we estimate we will conduct less
than 1 percent of these hearings by phone while we will conduct the
remaining 19 percent via video teleconferencing). Depending on the
claimant's response, the ALJ will: 1) prepare for the hearing as
scheduled; or 2) reschedule the hearing for a different date or
location. In situations where claimants do not want a video
hearing, the ALJ may reschedule the hearing as a face-to-face
hearing. The respondents are applicants for Social Security
benefits who request a hearing to appeal an unfavorable entitlement
or eligibility determination.
US Code:
42
USC 405 Name of Law: Social Security Act
US Code: 42
USC 1383 Name of Law: Social Security Act
US Code: 42 USC 401, 404, 405, 421, 423,
& 405 Name of Law: Social Security Act
US Code: 42 USC 902, 1381, 1381a, 1383, &1383b Name of Law:
Social Security Act
We increased the burden for the
HA-504 due to an increase in the number of annual respondents. In
addition, to accommodate our new regulations, we are adding
telephone hearings as a new modality. Respondents will be able to
choose telephone hearings in place of in-person hearings (see
Addendum for details).
$264,786
No
No
No
No
No
Uncollected
Faye Lipsky 410 965-8783
faye.lipsky@ssa.gov
No
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.
Form HA-504 Acknowledgement of Receipt (Notice of Hearing) - HA-504 (with teleconferencing)
Addendum - 0671.docx
Acknowledgement of Receipt (Notice of Hearing) - HA-504 (with teleconferencing)