Form i561 (Internet Ver i561 (Internet Ver Request for Reconsideration

iAppeals Screens for the final PSA (May 24)

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Welcome!
This is the starting point to request a review of our medical decision about
your eligibility for disability benefits. There are two parts to this Internet
Appeal process: (1) an Appeal Request form; and (2) an Appeal Disability
Report that gives us more information about your condition. You can
complete both forms online. To appeal online, you may submit only an
appeal request (Part 1). We are asking you to also submit an Appeal
Disability Report (Part 2) because it will give us more information about you
and help us in processing your appeal. If you do not want to use the
Internet to request your appeal, there are Other Ways to Request an Appeal
or Complete a Disability Report.
NOTE: We use the term “claimant” to refer to the adult or child whose
disability decision is being appealed.
To be able to use this Internet process, the claimant must:
Have applied for benefits
Have received a “Notice of Disapproved Claim”, a “Notice of
Reconsideration”, or “Notice of Federal Reviewing Official Decision”, and
have the notice available when beginning this process. (If you do not
know which notice you received, refer to About Your Notice.)
Disagree with the disability decision
Live in the United States or one of its territories
If any of the above statements are not true, stop here
and contact Social Security!
Completing the Internet Appeal Process
The first part of your appeal is the Appeal Request. The next five pages
explain this request and help you get ready to provide the information we
need. The sixth page is the Appeal Request form. We will ask you to
provide information about your representative if you have one. You will be
able to review the information you provide before sending it to us
electronically. The Appeal Request is a short form and you must complete
and submit it in a single session. You will not be able to come back to it
later.
Part 2 of the two-part Internet process is completing the Appeal Disability
Report. We will walk you through completion of this report right after you
submit the Appeal Request. The Report asks you to tell us about any
changes that have occurred since the claimant last completed a disability
report. This includes information about the claimant’s condition, doctors or
other medical sources and treatment, work activity and education. You do
not have to complete this report all at once. Later we will tell you how to
return to an Appeal Disability Report that you had started earlier.
To start the Internet Appeal Request and Disability Report process,
select this button.
Start the Appeal
Already started an Appeal Disability Report? Then select this button.
Go Back to the Report I Already Started

If You Have Questions
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing,
call our toll-free “TTY” number, 1-800-325-0778. Representatives are
available Monday through Friday from 7 AM to 7 PM.

See below for
Privacy Act
Statement

More Information about Disability and the Appeal Process
How the Disability Appeals Process Works
Your Right to Representation
Social Security’s Definition of Disability for Adults
Social Security’s Definition of Disability for Children
Internet Security Policy
Social Security’s Accessibility Policy
Privacy Information
Information about Social Security’s Disability Programs
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iAppeals Screens for the final PSA (May 24)

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About This Internet Appeal Process

Using Social Security Online Services
Using the Internet Appeal Request and Disability Report gives you:
Security and privacy for your information.
Step by step instructions and examples to help you complete the
Appeal Request and the Disability Report.
A process to collect information that applies to you, similar to the
interview process in a Social Security Office.
The ability to work at your own pace, stopping when you want and
coming back to finish later.
What You Will Need
The Internet Appeal Request and Disability Report process asks for
information about the adult or child whose disability decision is being
appealed (the “Claimant”) and his or her medical history.
For us to decide that the Claimant is disabled under the Social
Security Act and its regulations, you must give us as much
information as possible so that we can contact your doctors and
hospitals directly to get your medical records. It is important that you
give us the names, addresses, and dates of treatment for all your
doctors and hospitals. The list below provides details about what you
will need.
For Part 1: The Appeal Request
Your Social Security Number, name, address, and telephone
number, if you have one.
Your Notice of Decision.
Information about your Representative, if you have one. Use this
link for more information about having a Representative.
For Part 2: The Disability Report
The name, address including ZIP code, and telephone number of
someone else who knows about your illnesses, injuries and
conditions (referred to only as conditions from here on) and can
give us information about you. (Note: The instructions page for
Part 2 provides a link for ZIP code lookup, if you need it.)
A description of any changes in your conditions since you last
completed a disability report, including new physical and mental
limitations and new conditions.
The names, addresses including ZIP codes, and telephone
numbers for all doctors, hospitals, and clinics that you have seen
since you last completed a disability report, and the dates you
saw them.
The name of each medical test that you have had since you last
completed a disability report, when and where the test was done,
and who ordered it.
The name of each current prescription and over-the-counter
medicine that you take and the doctor who prescribed it.
Other Information
Third Party Links: Some Social Security Online pages contain links to
third party sites not operated by SSA. Those sites are not within our
control and may not follow the same privacy, security, or accessibility
standards as ours. We are not responsible for the content or availability
of those sites, their partners, or advertisers.
Previous Page

Last edited 5/16/2007 9:42 AM

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iAppeals Screens for the final PSA (May 24)

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Should You Use This Internet Appeal Process?
Not everyone will be able to complete this process online. You must
answer all of the following questions to help us determine if you should
use this Internet process or if it would be better for you to speak with a
Social Security representative.
Do you live in the
United States or one
of its territories/
commonwealths?

Yes

No

Did you receive a
notice of decision?

Yes

No

Continue

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iAppeals Screens for the final PSA (May 24)

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About Your Appeal

Thank you and welcome to the Internet Appeal Request.
Please answer the following questions to help us determine how to
guide you through the Internet Appeal process. If you are unsure of the
answers to any of these questions, please contact Social Security for
assistance.

Suffix (if any)

Claimant Name:
(Enter the First, Middle, and
Last Name of the person
applying for benefits.)

Claimant Social
Security Number:
Please enter the Social
Security Number without
dashes or hyphens.

Claimant date of
birth:
What is the date on
the “Notice of
Decision” you
received?
(If you do not know which
date we are referring to,
see What Is My Notice
Date?)

Continue

Last edited 4/6/2007 6:05 PM

iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

23

OMB No. 0960-0622

About the Request For Reconsideration

FIRST APPEAL: The letter you received about our determination on
your case tells you about your right to request a reconsideration of our
determination on your case. To request this review, you need to
complete an SSA-561-U2, Request for Reconsideration. The next few
pages allow you to electronically complete and submit the SSA-561.
The last page of Part 1 is a Receipt page with a date and time
confirmation that you should print and save for your records.
EVIDENCE: You should mail any information you have that shows our
original determination was not correct to the Social Security office
address provided at the end of Part 2. You should also complete the
SSA-3441, Disability Report - Appeal, and complete, sign and date the
SSA-827, Authorization to Disclose Information to SSA. The Appeal
Disability Report (SSA-3441) is Part 2 of this Internet Appeal process,
and it includes a link to the SSA-827.
You may also need to complete a form SSA-1696, Appointment of
Representative, if you are appointing a representative. If your
representative is not an attorney, he or she must sign the SSA-1696 or
state in writing that he or she accepts the appointment, before you send
it to us. Both the Appeal Request Receipt page and the Appeal
Disability Report include a link to the SSA-1696.

See below for
Paperwork
Reduction Act
Statement

If you have questions, you may call our toll-free number, 1-800-7721213, (for people who are deaf or hard of hearing, call our 'TTY' number,
1-800-325-0778), or contact your local Social Security Office. If you
contact us, please be sure to have in your possession any letters we
sent you. It will help us answer your questions.
We estimate you will need 18 minutes to complete this Request for
Reconsideration. If you want more information, use this link to read
about the Paperwork Reduction Act.
If you want to file your request for review online, please select the
Continue button to go to the next page. If you choose not to complete
your request online, please select the Exit button to leave this appeal
process.
Continue

Exit

Last edited 4/6/2007 6:09 PM

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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

24

Request For Reconsideration

Please enter your Appeal Request information.
Name of Claimant

John Public

(First, Middle, Last)

Claimant’s Mailing
Address:
Please provide a complete address, including apartment number if applicable. Please do NOT
use punctuation; for example, no periods or commas. Example: 528 Dawn St Apt 101
(Street Line 1)
(Street Line 2)
(City, State, Zip Code)

Claimant Telephone
Number:
Example: (111) 222-3333

Wage Earner Name (if
different from Claimant):
(First, Middle, Last)

Suffix (if any)

Who is the Wage Earner?

Claimant Social Security
Number (SSN)

xxx-xx-1234

Claimant Claim Number
(if different from SSN):
What is the Claim Number?

Supplemental Security
Income (SSI) Claim
Number:
What is the Claim Number?

I do not agree with the determination made on the above claim and request reconsideration.
My reasons are:
205 characters
maximum. This is
about 4 lines of
typing.
Count Characters

Do you currently have
a representative?
Select one:

Yes

No

I am completing this form as the Claimant.
I am completing this form as the Claimant’s Representative.

Select the Continue button to review your information before sending it
to the Social Security Administration. Select the Previous Page button
if you want to review the previous page of instructions.
Previous Page

Last edited 5/24/2007 1:56 PM

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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

26

Receipt of Request For Reconsideration
(Filed By Claimant)

We recommend that you print or save this page for your records now
because you will not be able to return to this page later. We have included
the details of the Request for Reconsideration that we received. If you disagree
with any of your statements, you should contact us within 10 days after [today’s
date] to let us know.
Next Steps
Carefully review the information below. Contact Social Security within ten
days if it is not correct.
Print and keep this confirmation page for your records. (Select this link to
print this page or save it to your computer. For instructions on how to print,
save, or view the saved file, please refer to the Print/Save/View Guide.)
Select the Start Part 2 button at the bottom of this page to begin Part 2 of the
Internet Appeal process, the Disability Report. We will not have all of the
information that we need to process your appeal until you submit the
Disability Report.

The Request for Reconsideration was
received by Social Security on [date] at [time].

Claimant’s name is [Claimant Name]. The Claimant’s mailing address is [Mailing
Address]. The Claimant’s phone number is [nnn-nnn-nnnn].
[Wage Earner’s or Self-Employed Person’s name, if different from the Claimant,
is [Wage Earner Name].]
Claimant’s Social Security Number is xxx-xx-1234. [Claimant’s Claim Number(s)
is/are xxx-xx-5678 A. The Supplemental Security Income (SSI) Claim Number is
xxx-xx-5678 A.]
I disagree with the determination made on my claim and request reconsideration.
My reasons are: [data entered].
[{I do not have a representative.
I understand that I have a right to be represented. If I am not represented but
would like to be, the Social Security office can give me a list of legal referral and
service organizations.}
or

{I am represented by [name], who [is/is not] an attorney. The Representative’s
address is [RAddress]. The Representative’s phone number is [nnn-nnn-nnnn]
[and fax number is [nnn-nnn-nnnn]].
If I am represented and have not done so previously, I will complete and submit
form SSA-1696 (Appointment of Representative).}]
Start Part 2

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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

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Receipt of Request For Reconsideration
(Filed By Representative)

We recommend that you print or save this page for your records now
because you will not be able to return to this page later. We have included
the details of the Request for Reconsideration that we received. If you disagree
with any of your statements, you should contact us within 10 days after [today’s
date] to let us know.
Next Steps
Carefully review the information below. Contact Social Security within ten
days if it is not correct.
Print and keep this confirmation page for your records. (Select this link to
print this page or save it to your computer. For instructions on how to print,
save, or view the saved file, please refer to the Print/Save/View Guide.)
Select the Start Part 2 button at the bottom of this page to begin Part 2 of the
Internet Appeal process, the Disability Report. We will not have all of the
information that we need to process your appeal until you submit the
Disability Report.

The Request for Reconsideration was
received by Social Security on [date] at [time].

Claimant’s name is [Claimant Name]. The Claimant’s mailing address is [Mailing
Address]. The Claimant’s phone number is [nnn-nnn-nnnn].
[Wage Earner’s or Self-Employed Person’s name, if different from the Claimant,
is [Wage Earner Name].]
Claimant’s Social Security Number is xxx-xx-1234. [Claimant’s Claim Number(s)
is/are xxx-xx-5678 A. The Supplemental Security Income (SSI) Claim Number is
xxx-xx-5678 A.]
The Claimant disagrees with the determination made on his or her claim and
requests reconsideration. The reasons are: [data entered].
The Claimant is represented by [name], who [is/is not] an attorney. If not done so
previously, the Claimant will complete and submit form SSA-1696 (Appointment
of Representative). The Representative’s address is [Raddress]. The
Representative’s phone number is [nnn-nnn-nnnn] [and fax number is [nnn-nnnnnnn].]
Start Part 2

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iAppeals Screens for the final PSA (May 24)

Privacy Information

The Social Security Act (sections 205(a), 702, 1631(e)(1)(a) and (b), and
1869(b)(1) and (c), and Public Law 106-169 (Section 809(a)(1) of Sections
251(a)) and Section 1839(i) of the Act (P.L. 108-173) as appropriate)
authorizes the collection of information on this form. We need the
information to continue processing your claim. You do not have to give it,
but if you do not you may not receive benefits under the Social Security
Act. We may give out the information on this form without your written
consent if we need to get more information to decide if you are eligible for
benefits or if a Federal law requires us to do so. Specifically, we may
See revised
provide information to another Federal, State, or local government agency
Privacy
Act
which is deciding your eligibility
for a
government benefit or program; to
the President or Congressman
inquiring
on your behalf; to an independent
Statement below.
party who needs statistical information for a research paper or audit report
on a Social Security program; or to the Department of Justice to represent
the Federal Government in a court suit related to a program administered
by the Social Security Administration. We explain, in the Federal Register,
these and other reasons why we may use or give out information about
you. If you would like more information, get in touch with any Social
Security office, the Veterans Affairs Regional Office in Manila, or any U.S.
Foreign Service post.
We may also use the information you give us when we match records by
computer. Matching programs compare our records with those of other
Federal, State, or local government agencies. Many agencies may use
matching programs to find or prove that a person qualifies for benefits paid
by the Federal government. The law allows us to do this even if you do
not agree to it.
Explanations about these and other reasons why information about you
may be used or given out are available in Social Security offices. If you
want to learn more about this, contact any Social Security office, the
Veterans Affairs Regional Office in Manila, or any U.S. Foreign Service
post.

Close this window to return to the appeal process.
Last edited 4/6/2007 6:11 PM

33

iAppeals Screens for the final PSA (May 24)

See revised
Paperwork
Reduction Act
Statement below.

36

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 20
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING 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 1800-325-0778). 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.

Request for Reconsideration, SSA-561-U2
Privacy Act Statement
Collection and Use of Personal Information

Section 205(a), of the Social Security Act as amended, [42 U.S.C. 405(a)] and
Title 20 C.F.R. 404.907 - 404.922 and 416.1407 – 416.1422 authorize us to collect this
information. We will use the information you provide to help us determine your
entitlement to benefits. The information you provide on this form is voluntary.
However, we cannot reconsider the decision on your claim unless you furnish this
information.
We rarely use the information you provide on this form for any purpose other than for the
reasons explained above. 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 for Social
Security records (e.g., to the Government Accountability Office, General
Services Administration, National Archives Records Administration, 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 investigative 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 agencies 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 our Systems of Records
Notices entitled Claims Folder System 60-0089, Supplemental Security Income Record
and Special Veterans Benefits 60-0103, and the Medicare Database File 60-0321. The
notices, additional information regarding this form, and information regarding our
systems and programs, are available on-line at www.socialsecurity.gov or at any local
Social Security office.