Form HA-55 and Cover Le HA-55 and Cover Le Objection to Appearing by Video Teleconferencing

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

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

[OBO Name] on behalf of
[ClaimantFirstName][ClaimantLastName]
[OBO Address]

[ClaimantFirstName][ClaimantLastName]
[ClaimantAddress]

Dear [OBO Name] [Addressee]

The Appeals Council returned your case to us for further action. This letter
explains the hearing process and things that you should do now to get ready for your hearing.
The United States District Court returned your case to us for further
action. This letter explains the hearing process and things that you should do now to get ready for
your hearing. Thank you for your request for a hearing. We will
mail a Notice of Hearing to you at least 75 20 days before the date of
your hearing to tell you its time and place. Although we will make every effort to schedule your
hearing as soon as possible, there may be a delay. If you wish to discuss the status of your case,
you may call us or write to us. Our telephone number and address are at the top of this page.
We are required by the district court opinion dated May 28, 1985 in Martinez, et al. v. Secretary
of HHS, E.D.N.Y., No. 73 Civ. 900, to notify you of procedures available to you in the event of
unreasonable delay in processing your case. If, after requesting the status of your case, you
believe your case is being delayed unreasonably, you may apply to the United States District
Court for relief, including interim benefits.

The Appeals Council returned your case to us for further action. This letter
explains the hearing process and things that you should do now to get ready for your hearing.
We will send you a notice after we schedule your hearing. We will notify you at least
75 20 days before the date of your hearing. The notice will provide you with the
time and place of your hearing. We generally process requests for hearing by date order, with
the oldest receiving priority. However, we expedite cases returned from the Appeals Council.
We will schedule your hearing as soon as we can, which may take several months.

 The United States District Court returned your case to us for further
action. This letter explains the hearing process and things that you should do now to get ready for
your hearing. We will send you a notice after we schedule your hearing. We will notify you at
least 75 20 days before the date of your hearing. The notice will provide
you with the time and place of your hearing. We generally process requests for hearing by date
order, with the oldest receiving priority. However, we expedite cases returned from the Federal
Courts. We will schedule your hearing as soon as we can, which may take several months.
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 send you a notice after we schedule your hearing. We will notify
you at least 75 20 days before the date of your hearing. The notice will
provide you with the time and place of your hearing. We generally process requests for hearing
by date order, with the oldest receiving priority. We will schedule your hearing as soon as we
can, which may take several months.

Use of Video Teleconferencing (VTC) At Your Hearing
In certain situations, we may hold your hearing by VTC rather than in person. We will let
you know ahead of time if we schedule your hearing by VTC.
If we schedule your appearance by VTC, you and the ALJ will be at different locations
during the hearing. A large, color monitor will enable 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 family member. We will provide someone at the hearing location to run the
equipment and provide any other help you may need.
You must let us know within 30 days after the date you receive this notice if you do
not want to appear at your hearing by VTC. (We may extend the 30-day period if you
show you had good cause for missing the deadline.) Please ask your
representative to return the form ONLY if you do not want to appear by VTC. (We
sent a business reply envelope to your representative.)Please return the form
in the envelope we sent you ONLY if you do not want to appear by VTC.We
will arrange for you to appear in person.
If you move before we hold your hearing, we retain the right to decide how you will
appear at your hearing, even if you objected to appearing by VTC. For us to consider
your change of residence when we schedule your hearing, you must submit evidence
proving your new residence.

Subsequent Application

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Our records show that you have a prior application(s) pending at the Appeals Council.
We will not act on your current request for a hearing until the Appeals Council completes
its action on your prior application(s). The Appeals Council will complete its action as
soon as possible and send you a notice explaining the outcome.


If the Appeals Council denies or dismisses your request for review or makes a
partially favorable or unfavorable decision on your prior application(s), we will hold
a hearing on your current application(s). We will send you a Notice of Hearing at
least 75 20 days before the date of your hearing to tell you
its time and place.



If the Appeals Council decides to remand your prior application(s) for a new hearing,
we may combine your prior and current applications for the new hearing. We will
send you a Notice of Hearing at least 75 20 days before the
date of your hearing to tell you its time and place.



If the Appeals Council makes a favorable decision on your prior application(s) that
resolves all the issues in the current application(s), we will take no further action on
your new application(s).

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 were decided in your favor in the 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.

Your Right To Representation
You may choose to have a representative help you. We will work with this person just as
we would work with you. If you decide to have a representative, you should find one
quickly so that person can start preparing your case.
Many representatives charge a fee only if you receive benefits. Others may represent you
for free. Usually, your representative may not charge a fee unless we approve it. We are
enclosing a list of groups that can help you find a representative.
If you get a representative, you or that person must notify us in writing. You may use our
Form SSA 1696-U4 Appointment of Representative. Any local Social Security office
can give you this form.

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.
We must receive any additional evidence no later than five business days before
the date of your hearing. The ALJ may choose to not consider the evidence if you fail to
provide it timely. 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 10 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,

[Signee Name]
[Signee Title]

Enclosures:
Claimant’s copy (if Spanish notice is not selected)
SSA Publication No. 05-10075 (Your Right To Representation) if no rep
HA-L1 (Important Notice Regarding Representation) if no rep
HA-L4 (What Happens Next) if What Happens Next is checked
HA-55 (Objection to Appearing by Video Teleconferencing)
HA-827 (Medical Release Notice) if Med. Release Notice and Form is checked
SSA-827 (Authorization to Disclose Information to SSA) if Med. Release Notice and Form is
checked
SSA Publication No. 70-067 (Why You Should Have Your Hearing By Video)
Representative’s copy
Form HA-L2 (Request for Hearing Acknowledgement Letter - Spanish) if Spanish notice is
checked
HA-L4-SP (What Happens Next - Spanish) if Spanish notice is checked and What Happens Next
is checked
HA-L4 (What Happens Next) if What Happens Next is checked
HA-55 (Objection to Appearing by Video Teleconferencing)
Form SSA-L1697-U3 (Acknowledgement of Representation)
Form HA-L32 (Electronic Disability Claims Processing Insert) if fully electronic
HA-827 (Medical Release Notice) if Med. Release Notice and Form is checked
SSA-827 (Authorization to Disclose Information to SSA) if Med. Release Notice and Form is
checked
SSA Publication No. 70-067 (Why You Should Have Your Hearing By Video)
Barcode Sheet if fully electronic

cc: [Rep First Name] [Rep Last Name]
[Rep Address]

Form HA-L2 (xx-2014)

Form Approved
OMB 0960-0671

Social Security Administration

OBJECTION TO APPEARING BY VIDEO TELECONFERENCING
Name:
Social Security Number:
Wage Earner:
Hearing Office:

[ ]
Added
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I do not want to appear at my hearing by video teleconference. Please schedule my
hearing so that I may appear in person.
Please return this form only if you object to a hearing by video teleconference.

Additional Comments:________________________________________________________________________________________

Signature:

Form HA-55 (12-2014)

Date:

Area Code and Telephone Number:

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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(b)(1), 205(d) and 1631(c) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to acknowledge you are opting-out of an appearance
via video teleconferencing.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination regarding
benefits eligibility. However, we may use the information for the administration of our programs including
sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under
contract with us).
A complete list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notice 60-0089, entitled Claims Folder System. Additional information
about this and other system of records notices and our programs are available online at
www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or local
government agencies. We use the information from these programs to establish or verify a person’s
eligibility for federally funded or administered benefit programs and for repayment of incorrect
payments or delinquent debts under these programs.
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 (12-2014)