Request for Hearing By Administrative Law Judge--Internet Version (i501)

Request for Hearing By Administrative Law Judge

i501 - Revised iAppeals Screens

Request for Hearing By Administrative Law Judge--Internet Version (i501)

OMB: 0960-0269

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0269 can be found here:

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IAPPEALS REVITALIZATION 2013

SCREEN PACKAGE
VERSION 2.2

iAppeals Revitalization 2013: Screen Package v. 2.2

Contents
1. Screen Package Version Information .................................................................................................................. 7
2. About this Screen Package .................................................................................................................................. 7
3. Third Party Screen Designs ................................................................................................................................. 8
3.1. Welcome Page ............................................................................................................................................. 8
3.2. Screening...................................................................................................................................................... 9
3.3. Screening: Lives in US ................................................................................................................................ 10
3.4. Who is Entering Appeal.............................................................................................................................. 11
3.5. Who is Entering Appeal: Entering for Sarah Jones .................................................................................... 12
3.6. Who is Entering Appeal: Representative Selected .................................................................................... 13
3.7. Who is Entering Appeal: Other Selected ................................................................................................... 14
3.8. Reentry Number – 3rd Party ....................................................................................................................... 15
3.9. Reentry Number – 3rd Party: Email Selected ............................................................................................. 16
3.10. Are You Sure You Want to Exit – 3rd Party ............................................................................................... 17
3.11. Return to a Saved Appeal – 3rd Party ....................................................................................................... 18
3.12. Who are You – 3rd Party ........................................................................................................................... 19
3.13. Who are You – 3rd Party: Someone Else .................................................................................................. 20
3.14. Who are You – 3rd Party: Other Selected ............................................................................................... 22
3.15. Preparer – 3rd Party................................................................................................................................. 23
3.16. Rep Information – 3rd Party Professional Rep ......................................................................................... 24
3.17. Applicant Info – 3rd Party ......................................................................................................................... 25
3.18. Rep – 3rd Party.......................................................................................................................................... 27
3.19. Rep – 3rd Party: Yes Selected ................................................................................................................... 28
3.20. Request for Reconsideration – 3rd Party................................................................................................. 29
3.21. Request for Hearing – 3rd Party ............................................................................................................... 30
3.22. Someone We Can Contact – 3rd Party .................................................................................................... 31
3.23. Someone We Can Contact – 3rd Party: No one selected ........................................................................ 32
3.24. Someone We Can Contact – 3rd Party: Someone else selected ............................................................. 33
3.25. Someone We Can Contact – 3rd Party: Follow up questions .................................................................. 34
3.26. Someone We Can Contact – 3rd Party: Terry Halpern selected.............................................................. 36
3.27. Someone We Can Contact – 3rd Party: Professional Rep ....................................................................... 37
3.28. Section3: Medical Conditions – 3rd Party................................................................................................ 38
3.29. Section3: Medical Conditions – 3rd Party: Follow up questions ............................................................. 39
3.30. Section3: Medical Conditions – 3rd Party: Remarks Pop Up ................................................................... 40
3.31. Section4: Medical Treatment – 3rd Party ............................................................................................... 41
3.32. Section4: Medical Treatment – 3rd Party: Follow up questions ............................................................ 42
2

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.33. Doctors & Hospitals – 3rd Party .............................................................................................................. 43
3.34. Add New Doctors – 3rd Party .................................................................................................................. 44
3.35. Add New Doctors – 3rd Party: Test Popup .............................................................................................. 47
3.36. Add New Doctors – 3rd Party: Test Popup with follow up question ....................................................... 48
3.37. Add New Doctors – 3rd Party: Medicine Popup ...................................................................................... 49
3.38. Doctors & Hospitals 1 Row Filled – 3rd Party .......................................................................................... 50
3.39. Add New Hospitals – 3rd Party ............................................................................................................... 51
3.40. Add New Hospitals – 3rd Party: Yes to Treatment Dates ....................................................................... 54
3.41. Doctors & Hospitals 2 Rows Filled – 3rd Party......................................................................................... 57
3.42. Tests – 3rd Party ...................................................................................................................................... 58
3.43. Add New Test – 3rd Party ....................................................................................................................... 59
3.44. Add New Test – 3rd Party: Follow up question and Other Doctor ......................................................... 61
3.45. Add New Test – 3rd Party: Have not seen the doctor ............................................................................ 62
3.46. Add New Test – 3rd Party: Have seen the doctor................................................................................... 63
3.47. Add New Test – 3rd Party: Other Hospital.............................................................................................. 65
3.48. Tests 3 Rows Filled – 3rd Party ................................................................................................................ 67
3.49. Medicines – 3rd Party .............................................................................................................................. 68
3.50. Add New Medicine – 3rd Party ................................................................................................................ 69
3.51. Add New Medicine – 3rd Party: Other doctor ......................................................................................... 70
3.52. Add New Medicine – 3rd Party: Have not seen the doctor ..................................................................... 71
3.53. Add New Medicine – 3rd Party: Have seen the doctor ........................................................................... 72
3.54. Add New Medicine – 3rd Party: Other Hospital ...................................................................................... 75
3.55. Medicines 3 Rows Filled – 3rd Party ........................................................................................................ 78
3.56. Section5: Other Medical Info – 3rd Party ................................................................................................ 79
3.57. Section5: Other Medical Info – 3rd Party: Yes selected .......................................................................... 80
3.58. Add Other Medical Info – 3rd Party......................................................................................................... 81
3.59. Added Other Medical Info – 3rd Party..................................................................................................... 83
3.60. Section7: Activities – 3rd Party ................................................................................................................ 84
3.61. Section7: Activities – 3rd Party: Follow up question ............................................................................... 85
3.62. Section8: Work & Education – 3rd Party ................................................................................................. 86
3.63. Section8: Work Education – 3rd Party: Follow up question ................................................................... 87
3.64. Section9: Voc Rehab – 3rd Party: First follow up question .................................................................... 88
3.65. Section9: Voc Rehab – 3rd Party: Second follow up questions ............................................................... 89
3.66. Remarks – 3rd Party ................................................................................................................................. 90
3.67. Medical Release – 3rd Party .................................................................................................................... 91
3.68. Medical Release – 3rd Party: Applicant is Present ................................................................................... 92
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iAppeals Revitalization 2013: Screen Package v. 2.2

3.69. Medical Release – 3rd Party: Applicant is Not Present ............................................................................ 93
3.70. Medical Release – 3rd Party Professional Rep.......................................................................................... 94
3.71. Medical Release – 3rd Party Professional Rep: Has signed form ............................................................. 95
3.72. Medical Release – 3rd Party Professional Rep: Does not have signed form ............................................ 96
3.73. Medical Release – 3rd Party Professional Rep: Applicant is Present ....................................................... 97
3.74. Medical Release – 3rd Party Professional Rep: Applicant is Not Present................................................. 98
3.75. Overall Summary – 3rd Party Public ......................................................................................................... 99
3.76. Attach File: No Files Added .................................................................................................................... 104
3.77. Attach Files: File Details dialog box ....................................................................................................... 105
3.78. Attach Files: Browse for file to attach ................................................................................................... 106
3.79. Attach Files: Select Document Type ...................................................................................................... 107
3.80. Attach Files: One file attached ............................................................................................................... 108
3.81. Attach Files: Delete Confirmation .......................................................................................................... 109
3.82. Attach Files: Maximum (10) number of files attached .......................................................................... 110
3.83. Confirmation with Attachments – 3rd Party Public ................................................................................ 111
3.84. Confirmation without Attachments – 3rd Party Public: With Bullets..................................................... 112
3.85. Receipt Pop up without Attachments – 3rd Party Public ....................................................................... 113
3.86. Cover Sheet Popup – 3rd Party Public .................................................................................................... 118
3.87. Cover Sheet Content – 3rd Party Public.................................................................................................. 119
3.88. Overall Summary – Showing section for 3rd Party Professional Rep ..................................................... 120
3.89. Confirmation – 3rd Party Professional Rep............................................................................................. 121
3.90. Confirmation – 3rd Party Professional Rep: With Bullets ....................................................................... 122
3.91. Receipt Pop up – 3rd Party Professional Rep ......................................................................................... 123
4. First Party Screen Designs ............................................................................................................................... 128
4.1. Reentry Number – 1st Party ..................................................................................................................... 128
4.2. Reentry Number – 1st Party: Email Selected ............................................................................................ 129
4.3. Are You Sure You Want to Exit ................................................................................................................ 130
4.4. Return to a Saved Appeal ........................................................................................................................ 131
4.5. Who are You – 1st Party ........................................................................................................................... 132
4.6. Applicant Detail – 1st Party ...................................................................................................................... 133
4.7. Rep – 1st Party .......................................................................................................................................... 134
4.8. Rep – 1st Party: Yes Selected .................................................................................................................... 135
4.9. Request for Reconsideration – 1st Party .................................................................................................. 136
4.10. Request for Hearing – 1st Party .............................................................................................................. 137
4.11. Someone We Can Contact – 1st Party .................................................................................................... 138
4.12. Someone We Can Contact – 1st Party: Follow up questions ................................................................. 139
4

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4.13. Someone We Can Contact – 1st Party: No Contact ............................................................................... 140
4.14. Section3: Medical Conditions – 1st Party ............................................................................................... 141
4.15. Section3: Medical Conditions – 1st Party: Follow Up questions ............................................................ 142
4.16. Section4: Medical Treatment – 1st Party .............................................................................................. 143
4.17. Section4: Medical Treatment – 1st Party: Follow Up Questions ........................................................... 144
4.18. Doctors & Hospitals – 1st Party .............................................................................................................. 145
4.19. Add New Doctors – 1st Party .................................................................................................................. 146
4.20. Add New Doctors – 1st Party: Test Popup .............................................................................................. 149
4.21. Add New Doctors – 1st Party: Test Popup with follow up question ...................................................... 150
4.22. Add New Doctors – 1st Party: Medicine Popup ..................................................................................... 151
4.23. Doctors & Hospitals – 1st Party: 1 Row Filled......................................................................................... 152
4.24. Add New Hospitals – 1st Party ............................................................................................................... 153
4.25. Add New Hospitals – 1st Party: Yes to Treatment Dates....................................................................... 156
4.27. Doctors & Hospitals – 1st Party: 2 Rows Filled ....................................................................................... 159
4.28. Tests – 1st Party ..................................................................................................................................... 160
4.29. Add New Test – 1st Party ....................................................................................................................... 161
4.30. Add New Test – 1st Party: Follow up question and Other Doctor ........................................................ 163
4.31. Add New Test – 1st Party: Have not seen the doctor ............................................................................ 164
4.32. Add New Test – 1st Party: Have seen the doctor .................................................................................. 165
4.33. Add New Test – 1st Party: Other Hospital ............................................................................................. 168
4.34. Tests – 1st Party: 3 Rows Filled ............................................................................................................... 171
4.35. Medicines – 1st Party.............................................................................................................................. 172
4.36. Add New Medicine – 1st Party ............................................................................................................... 173
4.37. Add New Medicine – 1st Party: Other Doctor ........................................................................................ 174
4.38. Add New Medicine – 1st Party: Have not seen the doctor .................................................................... 175
4.39. Add New Medicine – 1st Party: Have seen the doctor ........................................................................... 176
4.40. Add New Medicine – 1st Party: Other Hospital ...................................................................................... 179
4.41. Medicines – 1st Party: 3 Rows Filled ...................................................................................................... 182
4.42. Section5: Other Medical Info – 1st Party................................................................................................ 183
4.43. Section5: Other Medical Info – 1st Party: Yes selected .......................................................................... 184
4.44. Add Other Medical Info – 1st Party: Details ........................................................................................... 185
4.45. Added Other Medical Info – 1st Party: One Row Filled .......................................................................... 187
4.46. Section7: Activities – 1st Party................................................................................................................ 188
4.47. Section7: Activities – 1st Party: Follow up question............................................................................... 189
4.48. Section8: Work & Education – 1st Party................................................................................................. 190
4.49. Section8: Work & Education – 1st Party: Follow up question ................................................................ 191
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4.50. Section9: Voc Rehab – 1st Party: First follow up question ..................................................................... 192
4.51. Section9: Voc Rehab – 1st Party: Second follow up questions .............................................................. 193
4.52. Remarks – 1st Party ................................................................................................................................ 194
4.54. Medical Release – 1st Party .................................................................................................................... 195
4.55. Overall Summary – 1st Party .................................................................................................................. 196
4.57. Attach Files: No Files Attached .............................................................................................................. 201
4.58. Confirmation – 1st Party ........................................................................................................................ 202
4.59. Receipt Pop up – 1st Party ...................................................................................................................... 203
4.60. Cover Sheet Popup – 1st Party ............................................................................................................... 208
4.61. Cover Sheet Content – 1st Party ............................................................................................................ 209

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iAppeals Revitalization 2013: Screen Package v. 2.2

1. Screen Package Version Information
The first release of this Screen Package as a project deliverable is numbered 1.0. The second release is 2.0.
Version
Number

Date

Content Revisions

Page
#

0.1 (Draft)

09/24/2013

1.0

10/28/2013

UXG final recommendations based on research, testing

Multiple

2.0

02/06/2014

Updated language based on Sponsor Language Change Requests (LCRs)

Multiple

2.1

02/07/2014

Removed the Attachment Utility screens, and made appropriate modifications to pages
affected by the removal of attachment utility screens

Multiple

2.2

02/11/2014

Addressed any omissions due to multiple screens or dynamic panel edits

Multiple

Revised
by

2. About this Screen Package
This screen package is intended to provide snapshots of the various possible states of the iAppeals screens.
There are some global changes for the prototype which are not reflected in this document.
1. There has been a change to the instructional text for dates. The UXG recommendation:
“Enter the closest date [you] can remember. Examples: 6/2/2013; June 2013; Summer 2013.”
will be changed in production to:
“If the exact date is unknown, enter an approximate date. Examples: 6/2/2013; June 2013; Summer
2013.”
2. There has been a change to the field label and instructional text for side effects (for medicines). The
UXG recommendation:
Describe any side effects Sarah Jones experienced while taking this medicine:
will be changed in production to:
Describe any side effects Sarah Jones has while taking this medicine:
If none, enter "None"
There are some additional minor inconsistencies (typographical errors) in the prototype that are incidental
and immaterial to the OMB approval process. The work effort of correcting the inconsistencies within the
prototype is prohibitively great, but these errors will be corrected in the production version of the application.

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3. Third Party Screen Designs
3.1. Welcome Page

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3.2. Screening

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3.3. Screening: Lives in US
If state or territory is selected here, it is propagated to Applicant Detail page.

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.4. Who is Entering Appeal

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3.5. Who is Entering Appeal: Entering for Sarah Jones

Contents of relationship drop list:
-Appointed Representative (Attorney) or Staff
Appointed Representative (Non-Attorney) or Staff
Family Member
Friend/Neighbor
Government Agency
Health Service Agency/Hospital
Non-Profit Organization/Legal Aid Group
Nursing Care Facility
Social Worker
Other

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.6. Who is Entering Appeal: Representative Selected

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3.7. Who is Entering Appeal: Other Selected

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3.8. Reentry Number – 3rd Party
Option to enter email address is not provided if the user navigates back to this page and already provided an
email address.

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.9. Reentry Number – 3rd Party: Email Selected
Option to enter email address is not provided if the user navigates back to this page and already provided an
email address.

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.10. Are You Sure You Want to Exit – 3rd Party

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.11. Return to a Saved Appeal – 3rd Party

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.12. Who are You – 3rd Party

The possibilities for the radio list are determined based on data already provided in the claim. The names
shown would correspond to the roles, which should be shown in the following order:
1.
2.
3.
4.
5.

claimant (always appears)
third party preparer, if any
person listed on "Someone we can contact" page, if any
representative, if any, if different from preparer
someone else, helping to appeal (always appears)

If option 5 is selected and completed, the data entered replaces any preparer information previously provided.

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.13. Who are You – 3rd Party: Someone Else

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iAppeals Revitalization 2013: Screen Package v. 2.2

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.14. Who are You – 3rd Party: Other Selected

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.15. Preparer – 3rd Party

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.16. Rep Information – 3rd Party Professional Rep
Note: the right-hand secondary navigation adjusts based on selections made in the screening stages. In this
example, the representative is completing the appeal.

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.17. Applicant Info – 3rd Party
State is prefilled based on selection on screening page, if applicable. Gender is only asked of third parties.

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iAppeals Revitalization 2013: Screen Package v. 2.2

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3.18. Rep – 3rd Party
This version of the Representative page would be shown only if a representative has not already been
identified.

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.19. Rep – 3rd Party: Yes Selected

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.20. Request for Reconsideration – 3rd Party

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.21. Request for Hearing – 3rd Party

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3.22. Someone We Can Contact – 3rd Party

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3.23. Someone We Can Contact – 3rd Party: No one selected

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.24. Someone We Can Contact – 3rd Party: Someone else selected

Contents of relationship drop list:
-Family Member
Friend/Neighbor
Government Agency
Health Service Agency/Hospital
Non-Profit Organization/Legal Aid Group
Nursing Care Facility
Social Worker
Other

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.25. Someone We Can Contact – 3rd Party: Follow up questions

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iAppeals Revitalization 2013: Screen Package v. 2.2

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.26. Someone We Can Contact – 3rd Party: Terry Halpern selected

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.27. Someone We Can Contact – 3rd Party: Professional Rep

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.28. Section3: Medical Conditions – 3rd Party

Note: the language for these questions has been changed per stakeholders. It does not reflect the recommendation of the User
Experience Group.
38

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3.29. Section3: Medical Conditions – 3rd Party: Follow up questions

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3.30. Section3: Medical Conditions – 3rd Party: Remarks Pop Up

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.31. Section4: Medical Treatment – 3rd Party

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.32. Section4: Medical Treatment – 3rd Party: Follow up questions

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.33. Doctors & Hospitals – 3rd Party

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3.34. Add New Doctors – 3rd Party

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iAppeals Revitalization 2013: Screen Package v. 2.2

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.35. Add New Doctors – 3rd Party: Test Popup

Contents of "Test Type" drop list:
-Biopsy
Blood Test (not HIV)
Breathing Test
Cardiac Catheterization
EEG (Brain Wave Test)
EKG (Heart Test)
Hearing Test
HIV Test
IQ Test
MRI / CT Scan
Speech / Language Test
Treadmill (Exercise Test)
Vision Test
X-Ray
Other
Of these Test Types, selection of the following items will dynamically display a Body Part:
Biopsy
X-Ray
Other
Selecting “Other” will also dynamically display a “Please specify test type” text field.

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.36. Add New Doctors – 3rd Party: Test Popup with follow up question

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.37. Add New Doctors – 3rd Party: Medicine Popup

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.38. Doctors & Hospitals 1 Row Filled – 3rd Party

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.39. Add New Hospitals – 3rd Party

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iAppeals Revitalization 2013: Screen Package v. 2.2

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iAppeals Revitalization 2013: Screen Package v. 2.2

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.40. Add New Hospitals – 3rd Party: Yes to Treatment Dates

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iAppeals Revitalization 2013: Screen Package v. 2.2

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iAppeals Revitalization 2013: Screen Package v. 2.2

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3.41. Doctors & Hospitals 2 Rows Filled – 3rd Party

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.42. Tests – 3rd Party
Table will be prefilled with what was entered in doctors/hospitals pages

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.43. Add New Test – 3rd Party

Contents of Test Type drop list:
-Biopsy
Blood Test (not HIV)
Breathing Test
Cardiac Catheterization
EEG (Brain Wave Test)
EKG (Heart Test)
Hearing Test
HIV Test
IQ Test
MRI / CT Scan
Speech / Language Test
Treadmill (Exercise Test)
Vision Test
X-Ray
Other
Of these Test Types, selection of the following items will dynamically display a Body Part field:
Biopsy
X-Ray
Other
Selecting “Other” will also dynamically display the “Please specify test type” question.
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iAppeals Revitalization 2013: Screen Package v. 2.2

Contents of "Who recommended..." drop list:
-(All doctors previously entered)
(All hospitals previously entered)
Other Doctor or Healthcare Provider
Other Hospital or Clinic
No one recommended or prescribed this medicine
I don’t know

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.44. Add New Test – 3rd Party: Follow up question and Other Doctor

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.45. Add New Test – 3rd Party: Have not seen the doctor

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.46. Add New Test – 3rd Party: Have seen the doctor

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iAppeals Revitalization 2013: Screen Package v. 2.2

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3.47. Add New Test – 3rd Party: Other Hospital

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iAppeals Revitalization 2013: Screen Package v. 2.2

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3.48. Tests 3 Rows Filled – 3rd Party

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.49. Medicines – 3rd Party
Table will be prefilled with information that was entered in doctors/hospitals pages. No medicines have been
provided yet in this example.

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.50. Add New Medicine – 3rd Party

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3.51. Add New Medicine – 3rd Party: Other doctor

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.52. Add New Medicine – 3rd Party: Have not seen the doctor

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.53. Add New Medicine – 3rd Party: Have seen the doctor

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iAppeals Revitalization 2013: Screen Package v. 2.2

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3.54. Add New Medicine – 3rd Party: Other Hospital

DCS/OSES/DUAPS/USSB/UXG

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iAppeals Revitalization 2013: Screen Package v. 2.2

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iAppeals Revitalization 2013: Screen Package v. 2.2

3.55. Medicines 3 Rows Filled – 3rd Party

DCS/OSES/DUAPS/USSB/UXG

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3.56. Section5: Other Medical Info – 3rd Party

DCS/OSES/DUAPS/USSB/UXG

iAppeals Revitalization 2013: Screen Package v. 2.2

3.57. Section5: Other Medical Info – 3rd Party: Yes selected

DCS/OSES/DUAPS/USSB/UXG

iAppeals Revitalization 2013: Screen Package v. 2.2

3.58. Add Other Medical Info – 3rd Party

DCS/OSES/DUAPS/USSB/UXG

iAppeals Revitalization 2013: Screen Package v. 2.2

DCS/OSES/DUAPS/USSB/UXG

iAppeals Revitalization 2013: Screen Package v. 2.2

3.59. Added Other Medical Info – 3rd Party

DCS/OSES/DUAPS/USSB/UXG

iAppeals Revitalization 2013: Screen Package v. 2.2

3.60. Section7: Activities – 3rd Party

DCS/OSES/DUAPS/USSB/UXG

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3.61. Section7: Activities – 3rd Party: Follow up question

DCS/OSES/DUAPS/USSB/UXG

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3.62. Section8: Work & Education – 3rd Party

DCS/OSES/DUAPS/USSB/UXG

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3.63. Section8: Work Education – 3rd Party: Follow up question

DCS/OSES/DUAPS/USSB/UXG

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3.64. Section9: Voc Rehab – 3rd Party: First follow up question

Vocational Rehabilitation

DCS/OSES/DUAPS/USSB/UXG

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3.65. Section9: Voc Rehab – 3rd Party: Second follow up questions

Vocational Rehabilitation

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3.66. Remarks – 3rd Party

DCS/OSES/DUAPS/USSB/UXG

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3.67. Medical Release – 3rd Party

DCS/OSES/DUAPS/USSB/UXG

iAppeals Revitalization 2013: Screen Package v. 2.2

3.68. Medical Release – 3rd Party: Applicant is Present

DCS/OSES/DUAPS/USSB/UXG

iAppeals Revitalization 2013: Screen Package v. 2.2

3.69. Medical Release – 3rd Party: Applicant is Not Present

DCS/OSES/DUAPS/USSB/UXG

iAppeals Revitalization 2013: Screen Package v. 2.2

3.70. Medical Release – 3rd Party Professional Rep

DCS/OSES/DUAPS/USSB/UXG

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3.71. Medical Release – 3rd Party Professional Rep: Has signed form

DCS/OSES/DUAPS/USSB/UXG

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3.72. Medical Release – 3rd Party Professional Rep: Does not have signed form

DCS/OSES/DUAPS/USSB/UXG

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3.73. Medical Release – 3rd Party Professional Rep: Applicant is Present

DCS/OSES/DUAPS/USSB/UXG

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3.74. Medical Release – 3rd Party Professional Rep: Applicant is Not Present

DCS/OSES/DUAPS/USSB/UXG

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3.75. Overall Summary – 3rd Party Public
Please note: If a Yes/No question is answered No, any conditional fields below are not displayed.

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3.76. Attach File: No Files Added

To add a file, user selects “Add File” button.

104

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3.77. Attach Files: File Details dialog box

User selects “Browse” button to locate file to attach.

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3.78. Attach Files: Browse for file to attach

User locates file, selects file, selects “Open”.

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3.79. Attach Files: Select Document Type

User would select the type of document being attached.
List of options for Attorney Representatives & Staff and Non-Attorney Representatives & Staff:












Appointment of Representative (SSA-1696)
Identifying Information for Possible Direct Payment of Authorized
Fees (SSA-1695)
Fee Agreement
Authorization to Disclose Information to the Social Security
Administration (SSA-827)
Questionnaire for Children Claiming SSI Benefits (SSA-3881)
Good Cause for Late Filing Statement
Representative Brief
Waiver of Your Right to Personal Appearance Before an
Administrative Law Judge (HA-4608)
Consent for Release of Information (SSA-3288)
Medical Evidence
Other Evidence or Form

Note that the following options are not displayed for others:




DCS/OSES/DUAPS/USSB/UXG

Identifying Information for Possible Direct Payment of Authorized
Fees (SSA-1695)
Fee Agreement
Representative Brief

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3.80. Attach Files: One file attached

108

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3.81. Attach Files: Delete Confirmation
If user selects “Delete” button for any file, dialog box is shown to confirm.

DCS/OSES/DUAPS/USSB/UXG

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3.82. Attach Files: Maximum (10) number of files attached
Since the user has added the maximum number of files allowed, the Add File button is no longer shown.

110

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3.83. Confirmation with Attachments – 3rd Party Public

186.4 Kb
201.7 Kb
388.1 Kb

This sample shows an appeal with 2 files attached and uploaded.

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3.84. Confirmation without Attachments – 3rd Party Public: With Bullets

112

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3.85. Receipt Pop up without Attachments – 3rd Party Public
Paragraph beginning "We may review..." is only displayed for a request for hearing, not a reconsideration.

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3.86. Cover Sheet Popup – 3rd Party Public

118

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3.87. Cover Sheet Content – 3rd Party Public

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119

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3.88. Overall Summary – Showing section for 3rd Party Professional Rep

120

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3.89. Confirmation – 3rd Party Professional Rep

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121

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3.90. Confirmation – 3rd Party Professional Rep: With Bullets

122

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3.91. Receipt Pop up – 3rd Party Professional Rep
Paragraph beginning "an Administrative Law Judge" is only displayed for a request for hearing, not a
reconsideration.

DCS/OSES/DUAPS/USSB/UXG

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4. First Party Screen Designs
4.1. Reentry Number – 1st Party
Option to enter email address is not provided if the user navigates back to this page and already provided an
email address.

128

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4.2. Reentry Number – 1st Party: Email Selected
Option to enter email address is not provided if the user navigates back to this page and already provided an
email address.

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4.3. Are You Sure You Want to Exit
If the user did not choose to email the reentry number from the Reentry Number page, the container with the
question "Would you like us to email you this reentry number?" - as shown on the Reentry Number page will be displayed here above the navigation bar. If the user emailed the number previously, the page will
display as shown here.

130

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4.4. Return to a Saved Appeal

OSES/DUAPS/USSB/UXG

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4.5. Who are You – 1st Party

claimant (always appears)
person listed on "Someone we can contact" page, if any
representative, if any
someone else, helping to appeal (always appears)

If option 4 is selected and completed, the data entered replaces the preparer information previously provided.
Further, if any option other than claimant is selected, user will be placed into third party path (see screen 3.13.
Who are You – 3rd Party: Someone Else).

132

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4.6. Applicant Detail – 1st Party

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4.7. Rep – 1st Party

134

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4.8. Rep – 1st Party: Yes Selected

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135

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4.9. Request for Reconsideration – 1st Party

136

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4.10. Request for Hearing – 1st Party

OSES/DUAPS/USSB/UXG

137

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4.11. Someone We Can Contact – 1st Party

Contents of relationship drop list:
-Family Member
Friend/Neighbor
Government Agency
Health Service Agency/Hospital
Non-Profit Organization/Legal Aid Group
Nursing Care Facility
Social Worker
Other

138

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4.12. Someone We Can Contact – 1st Party: Follow up questions

OSES/DUAPS/USSB/UXG

139

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4.13. Someone We Can Contact – 1st Party: No Contact

140

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4.14. Section3: Medical Conditions – 1st Party

OSES/DUAPS/USSB/UXG

141

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4.15. Section3: Medical Conditions – 1st Party: Follow Up questions

142

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4.16. Section4: Medical Treatment – 1st Party

OSES/DUAPS/USSB/UXG

143

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4.17. Section4: Medical Treatment – 1st Party: Follow Up Questions

144

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4.18. Doctors & Hospitals – 1st Party

OSES/DUAPS/USSB/UXG

145

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4.19. Add New Doctors – 1st Party

146

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OSES/DUAPS/USSB/UXG

147

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148

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4.20. Add New Doctors – 1st Party: Test Popup

Contents of "Test Type" drop list:
-Biopsy
Blood Test (not HIV)
Breathing Test
Cardiac Catheterization
EEG (Brain Wave Test)
EKG (Heart Test)
Hearing Test
HIV Test
IQ Test
MRI / CT Scan
Speech / Language Test
Treadmill (Exercise Test)
Vision Test
X-Ray
Other
Of these Test Types, selection of the following items will dynamically display a Body Part field:
Biopsy
X-Ray
Other
Selecting “Other” will also dynamically display the “Please specify type” question.

OSES/DUAPS/USSB/UXG

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4.21. Add New Doctors – 1st Party: Test Popup with follow up question

150

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4.22. Add New Doctors – 1st Party: Medicine Popup

OSES/DUAPS/USSB/UXG

151

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4.23. Doctors & Hospitals – 1st Party: 1 Row Filled

152

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4.24. Add New Hospitals – 1st Party

OSES/DUAPS/USSB/UXG

153

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154

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OSES/DUAPS/USSB/UXG

155

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4.25. Add New Hospitals – 1st Party: Yes to Treatment Dates

156

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OSES/DUAPS/USSB/UXG

157

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158

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4.27. Doctors & Hospitals – 1st Party: 2 Rows Filled

OSES/DUAPS/USSB/UXG

159

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4.28. Tests – 1st Party
Table will be prefilled with what was entered in doctors/hospitals pages

160

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4.29. Add New Test – 1st Party

OSES/DUAPS/USSB/UXG

161

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Selecting “Other” will also dynamically display the “Please specify type” question.
Contents of "Who ordered..." drop list:
-(All doctors previously entered)
(All hospitals previously entered)
Other Doctor or Healthcare Provider
Other Hospital or Clinic
No one recommended or prescribed this medicine
I don't know

162

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4.30. Add New Test – 1st Party: Follow up question and Other Doctor

OSES/DUAPS/USSB/UXG

163

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4.31. Add New Test – 1st Party: Have not seen the doctor

164

DCS/OSES/DUAPS/USSB/UXG

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4.32. Add New Test – 1st Party: Have seen the doctor

OSES/DUAPS/USSB/UXG

165

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166

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iAppeals Revitalization 2013: Screen Package v. 2.2

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167

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4.33. Add New Test – 1st Party: Other Hospital

168

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OSES/DUAPS/USSB/UXG

169

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170

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4.34. Tests – 1st Party: 3 Rows Filled

OSES/DUAPS/USSB/UXG

171

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4.35. Medicines – 1st Party
Table will be prefilled with medicines previously entered in doctors/hospitals pages. No medicines has been
provided yet in this example.

172

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4.36. Add New Medicine – 1st Party

Contents of "Who ordered..." drop list:
-(All doctors previously entered)
(All hospitals previously entered)
Other Doctor or Healthcare Provider
Other Hospital or Clinic
No one recommended or prescribed this medicine
I don't know

OSES/DUAPS/USSB/UXG

173

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4.37. Add New Medicine – 1st Party: Other Doctor

174

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4.38. Add New Medicine – 1st Party: Have not seen the doctor

OSES/DUAPS/USSB/UXG

175

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4.39. Add New Medicine – 1st Party: Have seen the doctor

176

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OSES/DUAPS/USSB/UXG

177

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178

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4.40. Add New Medicine – 1st Party: Other Hospital

OSES/DUAPS/USSB/UXG

179

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180

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181

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4.41. Medicines – 1st Party: 3 Rows Filled

182

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4.42. Section5: Other Medical Info – 1st Party

OSES/DUAPS/USSB/UXG

183

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4.43. Section5: Other Medical Info – 1st Party: Yes selected

184

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4.44. Add Other Medical Info – 1st Party: Details

OSES/DUAPS/USSB/UXG

185

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186

DCS/OSES/DUAPS/USSB/UXG

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4.45. Added Other Medical Info – 1st Party: One Row Filled

OSES/DUAPS/USSB/UXG

187

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4.46. Section7: Activities – 1st Party

188

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4.47. Section7: Activities – 1st Party: Follow up question

OSES/DUAPS/USSB/UXG

189

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4.48. Section8: Work & Education – 1st Party

190

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4.49. Section8: Work & Education – 1st Party: Follow up question

OSES/DUAPS/USSB/UXG

191

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4.50. Section9: Voc Rehab – 1st Party: First follow up question

Vocational Rehabilitation

192

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4.51. Section9: Voc Rehab – 1st Party: Second follow up questions

Vocational Rehabilitation

OSES/DUAPS/USSB/UXG

193

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4.52. Remarks – 1st Party

194

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4.54. Medical Release – 1st Party

OSES/DUAPS/USSB/UXG

195

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4.55. Overall Summary – 1st Party
Please note: If a Yes/No question is answered No, any conditional fields below are not displayed.

196

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OSES/DUAPS/USSB/UXG

197

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198

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OSES/DUAPS/USSB/UXG

199

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200

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4.57. Attach Files: No Files Attached

OSES/DUAPS/USSB/UXG

201

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4.58. Confirmation – 1st Party
This is a sample of a confirmation for a request for Reconsideration.

202

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4.59. Receipt Pop up – 1st Party
In the green Confirmation notice, the paragraph beginning "an Administrative Law Judge” is only displayed for
a request for hearing, not reconsideration.

OSES/DUAPS/USSB/UXG

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207

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4.60. Cover Sheet Popup – 1st Party

208

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4.61. Cover Sheet Content – 1st Party

OSES/DUAPS/USSB/UXG

209

File Type	application/pdf
Author	Rhody, Alan
File Modified	2014-07-23
File Created	2014-06-13