Addendum to the Supporting Statement for 0960-0277

Addendum to the Supporting Statement for Form HA-520

Request for Review of Hearing Decision/Order

20 CFR 404.967-404.981, 20 CFR 416.1467-416.1481

OMB 0960-0277

Revisions to the HA-520:

• Top of form currently shows: SOCIAL SECURITY ADMINISTRATION/OFFICE OF HEARINGS AND APPEALS. This will be revised to: SOCIAL SECURITY ADMINISTRATION/OFFICE OF DISABILITY ADJUDICATION AND REVIEW.

• The instructions below the title instruct the claimant/representative to: Take or mail the signed 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. Currently, approximately 60-70 percent of requests for review are filed directly with the Appeals Council. Moreover, the Appeals Council’s address is shown at the bottom of the form. Accordingly, the instruction will be changed to read: Either mail the signed original form to the Appeals Council at the address shown below or take or mail the signed original to your local Social Security office ... .

• Below Box 11, the Appeals Council address block will read:

APPEALS COUNCIL

OFFICE OF DISABILITY ADJUDICATION AND REVIEW, SSA

5107 LEESBURG PIKE

FALLS CHURCH, VA 22041-3255

• In Box 12, the second box will read:

Disability-Worker (DIWC)

• Also, in Box 12, we will delete the Health Insurance - Part A (HIA) and Health Insurance - Part B (HIB) references. The Appeals Council no longer has jurisdiction over Health Insurance appeals.

Upon approval of these revisions, SSA’s Forms Management Team will make the changes to the form.