Addendum to the Supporting Statement for 0960-0269

Addendum to Supporting Statement for Form HA-501

Request for Hearing by Administrative Law Judge

20 CFR 404.929, 404.933, 416.1429, 416.1433, 42 CFR 405.722, 20 CFR 418.1350

OMB No. 0960-0269

Revisions to the Collection Instruments

To improve the quality of service we provide the public, we are updating the iAppeals application by adding the function to file a non-medical appeal through iAppeals using the internet versions of the i561 (Request for Reconsideration; OMB # 0960-0622) and i501 (Request for Hearing by Administrative Law Judge; OMB # 0960-0269). Overpayment; date of birth; substantial gainful activity; income and resources are some examples of non-medical issues (decisions) which an individual can appeal. Currently, individuals may only appeal medical decisions using iAppeals, the i561 or i501 and i3441 (Disability Report; OMB # 0960-0144); however, we are also adding functionality for non-medical appeals.

Revisions to the iAppeals Application

• Change #1: Add a new Welcome – Appeal a Decision Screen.

Justification #1: We are adding this screen to reflect that iAppeals accepts appeals for medical and non-medical decisions. On this screen, an individual will choose to appeal a medical decision or non-medical decision.

New Non-Medical i501 Screens for iAppeals:

• Change #1: Add the Non-Medical Appeal – Getting Ready screen.

Justification #1: We are adding this screen to provide information about the appeal process for non-medical appeals. This screen is where an individual will start the

non-medical appeal.

• Change #2: Add the Non-Medical Appeal – Information about the applicant screen.

Justification #2: We are adding this screen to collect the name, social security number, and date of birth for the individual who has the right to appeal the

non-medical decision.

• Change #3: Add the Information You Need to Complete Your Non-Medical Appeal screen.

Justification #3: We are adding this screen so that the individual will know what information that they will need to complete the hearing request.

• Change #4: Add the Non-Medical Appeal – Notice Information screen.

Justification #4: We are adding this screen to collect information on whether the individual has a notice from SSA; can use iAppeals to appeal the non-medical decision; and to determine the appeal level of the decision the individual wants to appeal.

• Change #5: Add the Non-Medical Appeal - Who is Entering This Appeal screen.

Justification #5: We are adding this screen to collect whether the individual completing the appeal is a first party, or a third party on behalf of the first party. Third parties must provide their names and relationship to the individual.

• Change #6: Add the Non-Medical Appeal – Information about you screen.

Justification #6: We are adding this screen to collect the individual’s contact information (mailing address, home address, telephone number, and email address).

• Change #7: Add the Non-Medical Appeal – Representative screen.

Justification #7: We are adding this screen to collect whether the individual has an appointed representative and, if so, the appointed representative’s contact information (address, telephone number, and fax number).

Change #8: Add the Non-Medical Appeal – Information about the Third Party Preparer screen.

Justification #8: We are adding this screen to collect a third party preparer’s contact information (mailing address and telephone number).

• Change #9: Add the Non-Medical Appeal – Request for Hearing by Administrative law Judge screen.

Justification #9: We are adding this screen to collect information about the decision the individual is appealing (notice date; Social Security Administration program title; reason for disagreeing with the decision; and whether the individual wants to appear at the hearing).

• Change #10: Add the Non-Medical Appeal – Attach Files screen.

Justification #10: We added this screen to provide an individual the option to upload and submit supporting documents along with the hearing request.

• Change #11: Add the Non-Medical Appeal – Overall Summary screen.

Justification #11: We are adding the Overall Summary screen so that an individual will have the opportunity to review and if necessary, update the information provided for the hearing request before they submits it to SSA. If there are no changes, the individual submits the hearing request. If there are changes, the individual updates the information and then submits the hearing request.

• Change: #12: Add the Non-Medical Appeal – Confirmations for Request for Hearing by an Administrative Law Judge.

Justification #12: We added this screen to confirm to the individual that SSA received the hearing request.

• Change #13: Add the Non-Medical Appeal – Information You submitted screen.

Justification #13: We are adding this screen so individuals can print or save a receipt for the information they submitted to SSA.

• Change #14: Add the Cover Sheet screen.

Justification #14: We are adding the Cover Sheet screen so individuals have the office information for the office handling the hearing request and to which they may submit additional documents or forms that support the hearing request.

• Change #15: Add the Non-Medical Appeal Definition: Appointed Representative Screen.

Justification #15: We are adding this help screen to provide a definition for appointed representative. An individual can access this screen by selecting the question mark in the Do you currently have an appointed representative section of the Representative screen.

• Change #16: Add the Where to Find the Level of Appeal in the Notice screen.

Justification #16: We added this screen as a guide for reviewing the decision notice to find the appeal level for the issue that individual is appealing. An individual can access this screen by selecting the question mark in Level of Appeal section of the Notice Information screen.

• Change #17: Add the Where to Find this date screen.

Justification #17: We added this screen as a guide for finding the notice date on the decision notice. An individual can access this screen by selecting the question mark in the What is the date on notice you received section of the Request for Hearing screen.

• Change #18: Add the Where to find the SSA program title screen.

Justification #18: We added this screen as a guide for finding the program title on the decision notice. An individual can access this screen by selecting the question mark in SSA Program Title section of the Request for Hearing screen.

• Change #19: Add the option for appearing screen.

Justification #19: We added this screen to provide information about how individuals can make their appearance at the hearing. An individual can access this screen by selecting the question mark in Do you wish to appear section of the Request for Hearing screen.

SSA will implement the above changes upon OMB’s approval of this information collection request.

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