Form HA-55 Objection to Appearing by Video Teleconferencing

SOCIAL SECURITY ADMINISTRATION
Refer To: [Claimant SSN]
[Claimant Name]

Office of Disability Adjudication and Review
[Local Office Address]
Tel: [Local Office Phone]/ Fax: [Local Office
Fax]
[Current Date]

Claimant Name
Claimant Address

Dear Claimant Name:
Thank you for your request for a hearing before an administrative law judge (ALJ). This letter
explains the hearing process and things that you should do now to get ready for your hearing. We
will mail a Notice of Hearing to you at least 20 days before the date of your hearing to tell you
its time and place.
Use of Video Teleconferencing (VTC) At Your Hearing
You may be scheduled to appear at your hearing by video teleconference (VTC). If you are
scheduled to appear at your hearing by VTC, you will be at one location during the hearing, and
the ALJ will be at another location. A large, color monitor will allow you and the ALJ to see,
hear, and speak to each other. The ALJ will also be able to see, hear, and speak to anyone who
comes with you to the hearing. This may include your representative (if you have one), a friend,
or a member of your family. A person will be at your location to operate the equipment and
provide any other help you may need.
If you do not want to appear at a hearing by VTC, you must let this office know within 30 days
after the date you receive this letter. Please do this by completing and returning the form on the
last page of this letter. Mail it back to us in the enclosed envelope.
If you fail to return the form within 30 days after you receive this letter, you will not have
another opportunity to object to appearing at your hearing by VTC. If you return the form within
30 days after the date you receive this letter, we will arrange an in-person appearance for you,
except if you move to a new residence. However, if you change your residence while your
request for hearing is pending, we retain the right to determine how you will appear, even if you
object to appearing by video teleconference. For us to consider your change of residence when
we schedule your hearing, you must submit evidence verifying your new residence.
The Hearing
At your hearing, you may present your case to the ALJ who will make the decision on your
claim(s). The ALJ will consider the issue(s) you raise, the evidence now in your file, and any
additional evidence you provide. The ALJ may also consider other issues, including issues that

Form HA-55

were decided in your favor in the determination or decision you appealed. The Notice of Hearing
will list the issues the ALJ plans to consider at the hearing.
Your hearing is the time to explain why you believe the ALJ should decide the issues in your
favor.
Providing Additional Evidence
We need to make sure that your file has everything you want the ALJ to consider and any other
evidence the ALJ will need to decide your case. After the ALJ reviews the evidence in your file,
he or she may request more evidence to consider at your hearing.
If there is more evidence you want the ALJ to see, please give it to us as soon as possible. Giving
us evidence early can often help us review your case sooner. If there is evidence you cannot give
to us before the hearing, you may bring it to the hearing.
We can help you get evidence you believe the ALJ should see. If you need help, contact our
office, your local Social Security office, or your representative (if you appoint one) immediately.
If a physician, expert, or other person is not providing documents important to your case, you
may ask the ALJ to issue a subpoena. A subpoena is a special document that requires a person to
submit documents or to testify at your hearing. The ALJ will issue a subpoena only if he or she
thinks the evidence is necessary to decide your case, and the evidence cannot be obtained another
way. You must ask the ALJ to issue a subpoena at least 5 days before your hearing date. Send
your request in writing to the address at the top of the first page of this letter.
You May See The Evidence In Your File
If you wish to see the evidence in your file, you can see it on or before the date of your hearing.
If you wish to see your file before the date of your hearing, please call us as soon as you
reasonably can at the number at the top of the first page of this letter.
If You Have Any Questions Or Your Address Changes
If you have any questions, please call or write us. You must tell us if you change your address.
For your convenience, we gave you our telephone number and address on the first page of this
letter.

Sincerely yours,

Signature Name
Signature Title

Form HA-55

Possible enclosures listed below; appropriate ones need to be listed
Enclosures:
SSA Publication No. 05-10075 (Your Right To Representation)
HA-L1 (Important Notice Regarding Representation)
HA-L4 (What Happens Next)
HA-L86 (What is the National Hearing Center)
Form HA-55 (Questionnaire Notice)
Form HA-4631 (Claimant's Recent Medical Treatment)
Form HA-4632 (Claimant's Medications)
Form HA-4633 (Claimant's Work Background)
cc: [Rep First Name] [Rep Last Name]
[Rep Address]

Form HA-55

OBJECTION TO APPEARING BY VIDEO TELECONFERENCING
Name: [Claimant Name]
Social Security Number: [Claimant SSN]
Wage Earner:

[Wage Earner]

Hearing Office: [Hearing Office]

I do not want to appear at my hearing by video teleconference. Please schedule my hearing so
that I may appear in person.
Additional Comments:________________________________________________________________________________________

Signature:

Date:

Area Code and Telephone Number:

Privacy Act Notice Sections 205(a), 205(c)(2) and 233 of the Social Security Act (40 U.S.C. § 405 and 433), and the Federal Records Act of
1950 (64 Stat. 583), authorizes us to collect the information contained on this form. The information you provide will be used to give the
employee credit for the correct amount of wages he or she earned in a given tax year. Completion of this form is voluntary. However, failure to
provide all or part of the requested information may affect the processing of this form and could prevent the employee form acquiring his or her
correct earnings information.
We rarely use this information provided on this form for any other 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. As a quarterly record detail file to provide data in wage investigation cases;
2. As a primary working record file of all SSN holders;
3. To record the latest employer of a wage earner;
4. To provide information to employers/former employers for correcting or reconstructing earnings records and for Social Security tax
purposes; and,
5. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social Security programs.
This information may be provided to the Internal Revenue Service for tax administration purposes or the Department of Justice for investigating
and prosecuting violations of the Social Security Act. In addition, we may also use this information you provided 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 and administered benefit programs.
A complete list of routine uses for this information is available in Systems of Records Notice, entitled, Earnings Recording and Self-Employment
Income System, Social Security Administration Office of Systems, 60-0059. The notice, additional information regarding this form, and
information regarding our programs and systems, are available on-line 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.

Form HA-55