SSA-454-ICR - Paper Short Version with follow up EDCS Interview

Social Security Administration
«SSN»

Notice of Continuing Disability Review
«FOAddr1»
«FOAddr2»
«FOAddr3»
«FOCity», «FOState» «FOZIP»
Telephone: «EePhone»
TDD: «FOTDD»
Fax: «FOFax»
Office Hours: «FOHours»
July 16, 2009

«PNA1»
«PNA2»
«PNA3»
«PNA4»
«PNA5»
«City», «Stn» «ZIP»
Important Notice: You must complete and return this form or «YourBenys» «TitleText»
benefits may stop.
«Salut»:
We must review the cases of people getting disability benefits to make sure they are still disabled
under our rules. We may also review cases at other times.
We are writing to let you know that we are starting to review «YourBenys» disability case. We
have enclosed a pamphlet that will tell you more about the review.
What You Need To Do Now
We would like you to complete the enclosed forms and return them to us before «15daysDate».
If you have no questions, and if the forms are complete, please return them by mail.
The Information We Will Need
In most cases, a Social Security representative will contact you to ask additional questions after you
have mailed this form to us. We ask you to complete and mail the form before we call to save
time. If we call, we may ask for more information about:







Hospital stays and surgeries within the last 12 months, including the dates, reasons, and
complete addresses
Visits to doctors and clinics within the last 12 months, including the dates, reasons, and
complete addresses
Counseling and therapy
Schools and special classes or tutoring
Teachers and counselors who have knowledge of «YourBenys» condition
Name(s) and dosage of any medicine(s) «Beny» use

SSA-454-ICR Cover Letter Draft 06-05-09



Each employer's name and address, the dates worked, and the amount earned if «YouHave»
worked since we last reviewed «YourHis» case

How We Decide If You Are Disabled
Doctors and other trained staff will decide for us if «YourBeny's» condition has improved, and if
«you are Beny is» still disabled under our rules.
When we decide, we will write and let you know our decision. Our letter will tell you whether
«you are/ BenyIs» still disabled under our rules.
We may find that «you are/Beny is» no longer disabled under our rules and «YourHis» payments
and Medicare coverage could stop. If this happens, you can appeal our decision. If you appeal our
decision, you can also choose to have us to continue to pay you until we decide the appeal.
If We Do Not Hear From You
We may stop «YourBenys» «TitleText» benefits if you do not answer this letter by «15 daysDate»
or contact us by this date to tell us why we have not heard from you. Before we stop «YourHis»
benefits, we will send you another letter to explain our decision. The letter will also explain your
right to appeal the decision and how to continue getting payments during the appeal.
Information About Medical Assistance
If «YourHis» SSI stops, any medical assistance «YouHave» that is based on SSI may also stop. If
this happens, your medical assistance agency should contact you, or you can call them to see if
«Beny» qualify for continued medical assistance.
If You Want An Interpreter To Help You
If you need an interpreter to conduct Social Security business, we will supply one on request, free
of charge. If you want us to supply the interpreter, please call before you come to the office and
tell us what language you prefer to speak.
If You Have Any Questions
Please visit our internet web site at www.socialsecurity.gov for general information about Social
Security. You may call us toll-free at 1-800-772-1213, if you have any specific questions. We can
answer most questions over the phone. You may call our TTY number at 1-800-325-0778 if you are
deaf or hard of hearing. Please have this letter with you if you call or visit an office. It will help us
answer your questions. You may also call ahead to make an appointment if you plan to visit an
office. This will help us provide faster service when you arrive.

Enclosures:
Continuing Disability Review Report – Adult (SSA 454 ICR)

SSA-454-ICR Cover Letter Draft 06-05-09