Request for Review of Hearing Decision/Order - Internet Version

Request for Review of Hearing Decision/Order

i520 - Non-Medical Appeals Screen Package

Request for Review of Hearing Decision/Order - Internet Version

OMB: 0960-0277

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0277 can be found here:
2023-10-06 - No material or nonsubstantive change to a currently approved collection
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SCREEN PACKAGE DOCUMENT (SCREENSHOTS ONLY)
NON-MEDICAL APPEALS:
INTERNET VERSION 2.0

Screen Package Document – Non-Medical Appeals: Internet Version 2.0

Table of Contents
Pages ....................................................................................................................................................................... 4
1.1. Appeal a Decision ......................................................................................................................................... 5
1.2. Getting Ready............................................................................................................................................... 6
1.3. Information You Need ................................................................................................................................. 7
1.4. Screening...................................................................................................................................................... 8
1.5. Notice ........................................................................................................................................................... 9
1.6. Who is Entering Appeal.............................................................................................................................. 11
1.7. Your Information – 1st Party ...................................................................................................................... 15
1.8. Representative Information 1st Party ........................................................................................................ 17
1.9. Preparer Information 3rd Party .................................................................................................................. 18
1.10. Applicant Information 3rd Party ............................................................................................................... 19
1.11. Request for Reconsideration 1st Party ..................................................................................................... 22
1.12. Attach Files 1st Party & 3rd Party – No Selection ...................................................................................... 25
1.13. Summary 1st Party .................................................................................................................................... 30
1.14. Confirmation 1st Party. Note: Confirmations for Reconsideration 1st and Hearing 1st are the same as
shown below. .................................................................................................................................................... 31
1.15. Receipt 1st Party ....................................................................................................................................... 32
1.16. Request for Reconsideration 3rd Party..................................................................................................... 33
1.17. Summary 3rd Party ................................................................................................................................... 35
1.18. Confirmation 3rd Party Preparer. Note: Confirmations for Reconsideration 3rd and Hearing 3rd are the
same as shown below. ...................................................................................................................................... 36
1.19. Confirmation 3rd Party Representative .................................................................................................... 37
1.20. Receipt 3rd Party....................................................................................................................................... 38
1.21. Request for Hearing 1st Party ................................................................................................................... 39
1.22. Summary 1st Party Hearing ...................................................................................................................... 41
1.23. Receipt 1st Party Hearing ......................................................................................................................... 42
1.24. Cover Sheet for Hearing is the same as Reconsideration. ....................................................................... 43
1.25. Request for Hearing 3rd Party .................................................................................................................. 43
1.26. Summary 3rd Party Hearing ...................................................................................................................... 45
1.27. Receipt 3rd Party Hearing ......................................................................................................................... 46
1.28. Appointed Representative ....................................................................................................................... 48
1.29. Where to find the level of appeal in the notice ....................................................................................... 49
1.30. Where to find this date ............................................................................................................................ 50
1.31. Where to find the SSA program title ....................................................................................................... 51
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Screen Package Document – Non-Medical Appeals: Internet Version 2.0

1.32. Options for appearing .............................................................................................................................. 52

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Pages

Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.1. Appeal a Decision

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.2. Getting Ready

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.3. Information You Need

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.4. Screening

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.5. Notice

1.5.1.1. Yes

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.5.1.2. No

1.5.1.3. None of the above

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.6. Who is Entering Appeal

1.6.1. Who is Entering Appeal – 1st Party

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.6.2. Someone Else – 3rd Party

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.6.2.1. Representative

1.6.2.2. Preparer (Other than Attorney)

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.6.2.3. Other Preparer

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.7. Your Information – 1st Party

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.7.1.1. Your Information – 1st Party (Home Address is different from Mailing Address)

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.8. Representative Information 1st Party

1.8.1. Yes There Is a Representative

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.9. Preparer Information 3rd Party

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.10. Applicant Information 3rd Party

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.10.1. Applicant Information 3rd Party (Home Address is different from Mailing Address)

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.10.2. Representative Information 3rd Party – Yes There Is a Representative

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.11. Request for Reconsideration 1st Party

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.11.1. SSA Program Title – Droplist

1.11.2. Ways to Appeal for SSI (if SSI is selected)

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.11.3. Ways to Appeal for SVB (If SVB is selected)

1.11.4. Issue Being Appealed

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.12. Attach Files 1st Party & 3rd Party – No Selection

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.12.1. Attach Files – If either “Yes, I have documents in electronic format” OR “Yes, I have
both electronic and paper documents” is selected, show Upload File panel

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.12.2. Attach Files – If either “Yes, I have paper documents” OR “No, I don’t have any
documents to submit” is selected, Upload File panel is not shown. User is taken to Summary.

1.12.3. File Details

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.12.3.1. Attach Document

1.12.3.2. Document Type Droplist

1.12.3.3. Document Type is Selected

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.12.3.4. Attach Files – File Added

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.13. Summary 1st Party

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.14. Confirmation 1st Party. Note: Confirmations for Reconsideration 1st and Hearing 1st are
the same as shown below.

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.15. Receipt 1st Party

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.16. Request for Reconsideration 3rd Party

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.16.1. Ways to Appeal for SSI (If SSI is selected)

1.16.1.1. Ways to Appeal for SVB (If SVB is selected)

1.16.1.2. Issue Being Appealed

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.17. Summary 3rd Party

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.18. Confirmation 3rd Party Preparer. Note: Confirmations for Reconsideration 3rd and Hearing
3rd are the same as shown below.

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.19. Confirmation 3rd Party Representative

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.20. Receipt 3rd Party

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.21. Request for Hearing 1st Party

1.21.1. Wish to Appear

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.21.1.1. Wish to Appear is hidden when Medicare is selected under SSA Program Title

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.22. Summary 1st Party Hearing

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.23. Receipt 1st Party Hearing

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.24. Cover Sheet for Hearing is the same as Reconsideration.
1.25. Request for Hearing 3rd Party

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.25.1. Wish to Appear: If Medicare is selected, do not display the question related to the
appearance at the hearing.

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.26. Summary 3rd Party Hearing

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.27. Receipt 3rd Party Hearing

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.27.1. Cover Sheet 3rd Party

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.28. Appointed Representative

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.29. Where to find the level of appeal in the notice

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.30. Where to find this date

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.31. Where to find the SSA program title

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Screen Package Document – Non-Medical Appeals: Internet Version 1.0

1.32. Options for appearing

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File Type	application/pdf
Author	[email protected]
File Modified	2017-10-03
File Created	2017-10-03