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

Social Security Administration
Electronic Appeals Terms of Service
You are able to request an appeal electronically by using this application and agreeing to the
terms of service. To complete your appeal electronically, you must provide all of the information
identified below. If you do not wish to complete your appeal request electronically, or you are
unable to provide the information identified below within the appeal period, you may file your
appeal request by mail or visiting your local Social Security Office at “Other Ways to Complete
Your Disability Appeal.”
I Acknowledge:
•

I have 60 days to request an appeal of the determination or decision on my claim. My 60
days starts 5 days after the date on my Notice of Decision. I can file my appeal request
online, by mail, or by visiting the local Social Security office. I can find additional
information about the appeal process at www.socialsecurity.gov under the Appeals
Process key word search.

•

If I wish to submit evidence after I have submitted my appeal request, I can find the
address of where to submit the evidence at: www.socialsecurity.gov with the key word
search Social Security Office Locator. I understand that in order for SSA to consider my
evidence, I must submit the evidence before SSA makes a determination or decision on
my appeal request.

•

Request for Reconsideration – I understand that if I have evidence to submit, but I am not
able to submit it at the time I submit my appeal request, I must indicate so on my appeal
request. If SSA sends me a notice that requests the evidence, I understand that I have 15
days to submit it. If I do not submit my evidence within 15 days of the date on the notice,
SSA will start processing my appeal request without it. I understand that in order for SSA
to consider my evidence, I must submit it before SSA makes a determination on my appeal
request.

•

I must select “submit” on the Review Page within the application in order to file my appeal
request with SSA. If I exit the application before selecting “submit,” my appeal request
is not complete and will not be processed.
SSA needs the following Information to complete an electronic appeal:
Claimant’s Information
•

Date of Notice of Decision,

•

Name,

•

Social Security number,

•

Date of birth,

•

Mailing address,

•

Phone number, and

•

Valid email address.

Third Party Information
•

Representative's name,

•

address, and

•

phone number.

Medical Information (You may want to refer to your medical records and have your
medicine containers available)
•

Name, address, and phone number of a friend or relative who knows about your
medical condition.

•

Description of any change to your medical condition and any new medical
conditions.

•

Name, address, phone number, and visit dates of all health care providers, type of
treatments, and tests since you last gave us medical evidence.

•

Name of any medicine (prescription or over-the-counter) you are currently taking,
why you are taking it, any side effects, and the name of the doctor who
recommended or prescribed the medicine.

•

Description of any change in your daily activities, work, and education.

Submitting Evidence
•

I understand that I must inform SSA about or submit all evidence known to me that
relates to whether or not I am disabled or blind.

•

Evidence is anything that I submit, that anyone else submits, or that SSA obtains
that relates to my claim. Evidence includes treatment notes and medical opinions,
which are statements from medical sources about what I can still do despite my
impairment(s).
o

o

•

If I am unable to submit evidence at the time of my electronic appeal request,
I will indicate that “I have additional evidence to submit that is not electronic”
in the “I do not agree with the determination made on the above claim and
request reconsideration. My reasons are:” section.
If I wish to submit paper evidence to be considered with my appeal request I
can find the address at: www.socialsecurity.gov key word search Social
Security Office Locator.

I understand that once I submit my appeal electronically:
o

I will receive an on-screen confirmation that my request has been submitted
as well as an email confirmation, if an email address was provided.

o

o

SSA will provide a cover sheet, which can be printed and used to submit any
evidence that I want SSA to include with my appeal request.
If I indicated in my appeal request that I have additional evidence or SSA needs
additional information, a Social Security representative may contact me by
email, phone, or mail.

I understand that:
I can re-enter this application if:
o

I received a Re-entry number;

o

I did not submit my current appeal request; and

o

My appeal period has not expired.

I cannot re-enter this application if:
o

I did not receive a re-entry number;

o

The appeal period has expired; or

o

o

I already submitted an appeal request on the determination or decision that I am
attempting to appeal;
Note: If I want to add additional information to or change submitted information,
I will contact or mail, fax, or deliver paper copies of my evidence to my local Social
Security office.

If I would like a receipt for my appeal request:
o

I can log into my Social Security account,

o

Register for an account to check the status of my appeal, or

o

Contact my local Social Security office and request a receipt.

I understand that I may be subject to criminal or civil penalties, or both, if I provide false or
misleading statements, engage in unauthorized use of this system, or otherwise misuse this
system.
CHECK BLOCK HERE I agree to the Terms of Service.
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