Form HA-501 Request for Hearing By Administrative Law Judge

SOCIAL SECURITY ADMINISTRATION
Hearings Operations
OFFICE OF DISABILITY
ADJUDICATION AND REVIEW

Form Approved
OMB No. 0960-0269

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)

1. Claimant Name

2. Claimant SSN

See
Privacy Act Notice

3. Claim Number (if different from SSN)

4. I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE. I disagree with the determination because:

Hearings Operations
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.
<-------------------------------------------6. Do not complete if the appeal is a Medicare issue. Otherwise,
5. I have additional evidence to submit.
Yes
No
check one of the blocks.
Name and source of additional evidence, if not included.
I wish to appear at a hearing.
__________________________________________
I do not wish to appear at a hearing and I request that a
Submit your evidence to the hearing office within 10 days.
decision
be made based on the evidence in my case. (Complete
Your servicing Social Security office will provide the
Waiver Form HA-4608)
hearing office’s address. Attach an additional sheet if you
need more space.
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)
DATE

□

□

□
□

75 before the
date of
hearing from
the Social
Security
Administratio
n, and 20
days before
the date of
hearing from
the
Department

RESIDENCE ADDRESS

of Health and

ADDRESS

Human

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

TELEPHONE NUMBER
FAX NUMBER
TELEPHONE NUMBER
FAX NUMBER
(
)
(
)
(
)
(
)
TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION - ACKNOWLEDGMENT OF REQUEST FOR HEARING
9. Request received on_______________ by___________________________________________________________(SSA)
(Date)
(Print Name)
(Title)
_____________________________________________________________________________________________________
(Address)
(Servicing FO Code)
(PC Code)

□

10. Was the request for hearing received within 65 days of the reconsidered determination?
YES
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 claims that apply:

□ Yes □ No
□ No

service organizations provided?

□

12. Interpreter needed
Yes
Language (including sign language)_____________________

□ Initial Entitlement Case
□ Disability Cessation Case or □ Other Postentitlement
13. Check one:

Case
14. HO COPY SENT TO: __________ HO on ___________

□ Claims Folder (CF) Attached: □Title(T)II □T XVI
□T VIII □T XVIIII
□T II CF held in FO □Electronic Folder
□CF Requested □T II □T XVI □T VIII □T XVIII
(Copy of email or phone report attached)

□ NO

If no, attach

□ Retirement and Survivors Insurance Only
□ Title II Disability–Worker or child only
□ Title II Disability-Widow(er) only
□ Title XVI (SSI) Aged only
□ Title XVI Blind only
□ Title XVI Disability only
□ Title XVI/Title II Concurrent Aged Claim
□ Title XVI/Title II Concurrent Blind
□ Title XVI/Title II Concurrent Disability
□ Title XVIII Hospital/Supplementary Insurance

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

Services.

16. CF COPY SENT TO:_________ HO on __________

□CF Attached: □Title(T) II □T XVI □T XVIII
□Other Attached: _____________________
Form HA-501-U5 (00-0000) EF(00-0000)

□ Title VIII Only Special Veterans Benefits
□ Title VIII/Title XVI
□ Other – Specify___________________

(SVB)
(SVB/SSI)

TAKE OR MAIL THE 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.
See Revised Privacy Act Statement Attached
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 Disability 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.
See Revised PRA Statement Attached
TAKE OR MAIL 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 (00-000-2012) ef (00-0000)