Form HA-55 Objection to Appearing by Video Teleconferencing

Social Security Administration

OBJECTION TO APPEARING BY VIDEO TELECONFERENCING

Form Approved
OMB No. 0960-0671

Name:
Social Security Number:
Wage Earner:
Hearing Office: Office of Hearings and Appeals

[ ]

I do not want to appear at my hearing by video teleconference. Please schedule my
hearing so that I may appear in person. I understand that by objecting to appearing by
video teleconference that I may experience a delay in my hearing.
Please return this form only if you object to a hearing by video teleconference.

Additional Comments:________________________________________________________________________________________

Signature:

Date:

Area Code and Telephone Number:

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(b)(1), 205(d) and 1631(c) of the Social Security Act, as amended, authorize us to collect this information. We will use the information you provide
to acknowledge you are opting-out of an appearance via video teleconferencing. Furnishing us this information is voluntary. However, failing to provide us with
all or part of the information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination regarding benefits eligibility. However, we may use the
information for the administration of our programs including sharing information:
1.

To comply with Federal laws requiring the release of information from our records (e.g., to the Government Accountability Office and Department of
Veterans Affairs); and,

2.

To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and improvement of our programs (e.g., to the Bureau
of the Census and to private entities under contract with us).

We may share the information you provide to other health agencies through computer matching programs. Matching programs compare our records with records
kept by other Federal, State or local government agencies. We use the information from these programs to establish or verify a person’s eligibility for federally
funded or administered benefit programs and for repayment of incorrect payments or delinquent debts under these programs.
A complete list of when we may share your information with others, called routine uses, is available in our Privacy Act System of Records Notice 60-0089,
entitled Claims Folder System. Additional information about this and other system of records notices and our programs are available online at
www.socialsecurity.gov or at your 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 5 minutes to read the instructions, gather the facts, and answer the questions. 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.