Current HA-501

Form HA-501 (06-2022)
Discontinue Prior Editions
Office of Hearings Operations

OMB. No. 0960-0269
Page 1 of 2

REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE

See Privacy
Act Notice

(Take or mail the completed original to your local Social Security office, the Veterans Affairs Regional Office
in Manila or any U.S. Foreign Service post and keep a copy for your records)
2. Claimant SSN
3. Claim Number, if different
1. Claimant Name

4. I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE. I disagree with the determination because:

An Administrative Law Judge of the Social Security Administration's Office of Hearings Operations or the Department of Health
and Human Services will be appointed to conduct the hearing or other proceedings in your case. You will receive notice of the
time and place of a hearing at least 75 days before the date of hearing from the Social Security Administration, and 20 days
before the date of hearing from the Department of Health and Human Services.
6. Do not complete if the appeal is a Medicare
5. I have additional evidence to submit.
No
Yes
issue. Otherwise, check one of the blocks
Name and source of additional evidence, if not included.
I wish to appear at a hearing.
I do not wish to appear at a hearing and I
request that a decision be made based on
Submit your evidence to the hearing office within 10 days. Your servicing
the evidence in my case. (Complete
Social Security office will provide the hearing office's address. Attach an
Waiver Form HA-4608)
additional sheet if you need more space.
Representation: You have a right to be represented at the hearing. If you are not represented, your Social Security office will
give you a list of legal referral and service organizations. If you are represented, complete and submit form SSA-1696
(Appointment of Representative) unless you are appealing a Medicare issue.
7. CLAIMANT SIGNATURE (OPTIONAL)

DATE

RESIDENCE ADDRESS

8. NAME OF REPRESENTATIVE (if any)

DATE

ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

FAX NUMBER

CITY

STATE

TELEPHONE NUMBER

FAX NUMBER

ZIP CODE

TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION- ACKNOWLEDGMENT OF REQUEST FOR HEARING
9. Request received on
by:
(Date)

(Print Name)

(Address)

(Title)
(Servicing FO Code)

10. Was the request for hearing received within 65 days of the reconsidered determination?
Yes
No
If no, attach claimant's explanation for delay and supporting documents if any.
11. If claimant is not represented, was a list of legal referral
15. Check all claim types that apply:
Yes
No
service organizations provided?
Retirement and Survivors Insurance Only
12. Interpreter needed
Yes
No
Title II Disability - Worker or child only
Language (including sign language):
Title II Disability - Widow(er) only
13. Check one:
Initial Entitlement Case
Title XVI (SSI) Aged only
Disability Cessation Case or
Other Postentitlement Case
Title XVI Blind only
14. HO COPY SENT TO:
HO on
Title XVI Disability only
Claims Folder (CF) Attached:
Title (T) II;
T XVI;
Title XVI/Title II Concurrent Aged Claim
T VIII;
T XVIII;
T II CF held in FO
Electronic Folder
Title XVI/Title II Concurrent Blind
CF requested
T II;
T XVI;
T VIII;
T XVIII
Title XVI/Title II Concurrent Disability
(Copy of email or phone report attached)
Title XVIII Hospital/Supplementary Insurance
16. CF COPY SENT TO:
HO on
Title VIII Only Special Veterans Benefits
CF Attached:
Other Attached:

Title (T) II;

T XVI;

T XVIII

Title VIII/Title XVI
Other - Specify:

(PC Code)

(RSI)
(DIWC)
(DIWW)
(SSIA)
(SSIB)
(SSID)
(SSAC)
(SSBC)
(SSDC)
(HI/SMI)
(SVB)
(SVB/SSI)

Page 2 of 2

Form HA-501 (06-2022)

PRIVACY ACT STATEMENT
Collection and Use Of Personal Information
Sections 205, 1155, 1631(c), and 1869(b) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from making an accurate and timely decision on your claim.
We will use the information you provide to continue processing your claim. We may also share your
information for the following purposes, called routine uses:
• To contractors and other Federal agencies, as necessary, for the purpose of assisting Social Security
Administration (SSA) in the efficient administration of its programs. We contemplate disclosing information
under this routine use only in situations in which SSA may enter a contractual or similar agreement with a
third party to assist in accomplishing an agency function relating to this system of records; and
• To a congressional office in response to an inquiry from that office made at the request of the subject of a
record.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person’s eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices(SORN) 60-0009,
entitled Hearings and Appeals Case Control System, as published in the Federal Register (FR) on October
13, 1982, at 47 FR 45589 and 60-0089, entitled Claims Folder System, as published in the FR on April 1,
2003, at 68 FR 15784. Additional information, and a full listing of all of our SORNs, is available on our
website at www.ssa.gov/privacy.

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 10 minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your
local Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also listed
under U. S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778). 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.