Addendum to the Supporting Statement for 0960-0622

Addendum to the Supporting Statement for Form SSA‑561-U2

Request for Reconsideration

20 CFR 404.907-404.921, 416.1407-416.1421, 418.1009, and 418.1325

OMB No. 0960-0622

Background

Effective September 2007, a claimant who receives a DDS medical denial notice may appeal SSA’s determination by using the URL provided. The URL displays the Internet Appeal Process which is a two-part process. The first part is completing and submitting the appeal request (i561). The second part of the process is completing and submitting the Appeal Disability Report (i3441) which is cleared under OMB No. 0960-0144. We are limiting this clearance to the screens the individual will use to request a reconsideration. The clearance for the Appeal Disability Report (i3441) and the i61/SSA-61 (Request for Review by a Federal Reviewing Official, OMB No. 0960-0728) will be done separately.

The claimant who disagrees with SSA’s initial claim for disability will go into the Internet Appeal screen path, complete the questions (which follow the paper appeal form SSA-561-U2 (Request for Reconsideration), and submit his/her request for a reconsideration. The claimant will receive a confirmation page which includes the exact details of his/her submitted appeal. The confirmation page shows the date and time SSA received the request. The claimant can print and save this page for his/her records.

There is one change to the SSA-561-U2 as noted below. SSA made other revisions to the SSA-561-U2 to show the addition of Medicare Part B income-related premium subsidy reductions. The other revisions were cleared by OMB in August 2006.

REVISION TO SSA-561-U2

• Added Social Security Number (If Different)

Reason for change: SSN is needed for identification purposes for the Medicare Part B IRMAA.

Wording Differences between Internet Appeal Screen and the SSA-561-U2

Because the internet is a different medium from the paper forms used for an appeal, it was necessary to make slight changes to show the differences between the Internet Appeals screens and the SSA-561-U2. Those differences are shown below.

The first screen “Should You Use This Internet Appeal Process?” provides four mandatory questions that must be completed to determine if the individual should to use the internet process. Those questions are:

1. Claimant Name

2. Claimant Social Security Number

3. Claimant date of birth

4. Notice of Decision date (the date on the notice of decision the individual received)

If the individual does not know which date we are referring to, he/she is told to see “What Is My Service Date?

The next screen “About the Request for Reconsideration” provides a brief introduction into the internet Request for Reconsideration.

The next screen “How This Internet Appeal Request Works” provides an explanation on completing and submitting the Internet Appeal Request and how to move around in the Internet Appeal Request.

The next screen “Request for Reconsideration” begins completion of the SSA-561 Request for Reconsideration. This screen differs from the form as follows:

• Asks the question “Do you currently have a representative?” with a “Yes/No” box.

• States “If yes, select whether the individual is “completing this form as the Claimant” or “completing this form as the Claimant’s representative.”

This question is similar to the paper form but worded differently due to the difference in the medium. If the individual filing is the claimant, he/she will complete the Representative Information screen and the Submit Request for Reconsideration—Claimant screens. If filing as the representative, he/she will complete the Representative Information screen and the Submit Request for Reconsideration—Representative screens.

The next screen “Submit Request for Hearing by Administrative Law Judge—Claimant” provides the Penalty of Perjury clause and tells the claimant:

• To review this summary to ensure the answers were entered correctly.

• If you agree with all your statements, use the Sign and Submit button to send this appeal request to Social Security.

• If you disagree with any of your statements, use the Previous Page button to go back to the questions and correct the information.

• When you select “Sign Now,” you will be sending your completed application electronically to the Social Security Administration. You will no longer be able to change your information. Please review your information before selecting “Sign Now.”

The next screen “Confirmation for Request for Hearing by Administrative Law Judge—Claimant

• Recommends claimant print or save this page for his/her records.

• Includes the exact details of the submitted appeal.

• Provides instructions on how to print, save, or view the saved file.

• Provides the date and time the Request for Reconsideration was received by Social Security

• Under What You Need To Do tells claimant to

  • Review this summary to ensure we recorded your statements correctly.

  • Print and keep this confirmation page for your records.

  • If you disagree with any of your statements, you should contact us within 10 days after {today’s date} to let us know.

The next screen “Submit Request for Reconsideration—Representative” provides the Penalty of Perjury clause and tells the representative the same information as provided in the screen “Submit Request for Hearing by Administrative Law—Claimant”

The next screen “Confirmation for Request for Reconsideration—Representative” provides the same information as the screen “Confirmation for Request for Reconsideration—Claimant”