Form HA-501 Request for Hearing By Administrative Law Judge

Form Approved
OMB No. 0960-0269

SOCIAL SECURITY ADMINISTRATION
OFFICE OF DISABILITY ADJUDICATION AND REVIEW

REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE

(Take or mail the completed original to your local Social Security office, the Veterans Affairs Regional
Office in Manila or any U.S. Foreign Service post and keep a copy for your records)
2. Claimant SSN
3. Claim Number, if different
1. Claimant Name

See Privacy
Act Notice

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.

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

No

Yes

Name and source of additional evidence, if not included.

I wish to appear at a hearing.
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.

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)

RESIDENCE ADDRESS

DATE

ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

FAX NUMBER

CITY

STATE

TELEPHONE NUMBER

FAX NUMBER

ZIP CODE

TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION- ACKNOWLEDGMENT OF REQUEST FOR HEARING
9. Request received on
by:
(Date)

(Print Name)

(Address)

(Title)

(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:
Yes
No
service organizations provided?
Retirement and Survivors Insurance Only
12. Interpreter needed
Yes
No
Title II Disability - Worker or child only
Language (including sign language):
Title II Disability - Widow(er) only
13. Check one:
Initial Entitlement Case
Title XVI (SSI) Aged only
Disability Cessation Case or
Other Postentitlement Case
Title XVI Blind only
14. HO COPY SENT TO:
HO on
Title XVI Disability only
Claims Folder (CF) Attached:
Title (T) II;
T XVI;
Title XVI/Title II Concurrent Aged Claim
T VIII;
T XVIII;
T II CF held in FO
Electronic Folder
Title XVI/Title II Concurrent Blind
CF requested
T II;
T XVI;
T VIII;
T XVIII
Title XVI/Title II Concurrent Disability
(Copy of email or phone report attached)
Title XVIII Hospital/Supplementary Insurance
16. CF COPY SENT TO:
HO on
Title VIII Only Special Veterans Benefits
CF Attached:

Title (T) II;

T XVI;

Other Attached:
Form HA-501-U5 (01-2015) ef (01-2015)
Use 08-2012 Edition Until Stock is Exhausted

T XVIII

Title VIII/Title XVI
Other - Specify:

(RSI)
(DIWC)
(DIWW)
(SSIA)
(SSIB)
(SSID)
(SSAC)
(SSBC)
(SSDC)
(HI/SMI)
(SVB)
(SVB/SSI)

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

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)