CONTINUING DISABILITY REVIEW (CDR) RESPONSE

Social Security Administration

CLAIMANT INFORMATION

Claimant Name: _________________________________________________
Social Security Number: _____ - _____ - _________
Date of Birth: _________________
Current Age: _________

Contact Information:
Address: _________________________________________________
Phone: _________________
Email: _________________________________________________

Representative (if any):
Name: _________________________________________________
Phone: _________________
☐ Form SSA-1696 on file

CDR INFORMATION

Date CDR Notice Received: _________________

Type of CDR:
☐ Medical CDR (medical improvement review)
☐ Work CDR (review of work activity)

CDR Diary Category:
☐ Medical Improvement Expected (MIE) - typically 6-18 months
☐ Medical Improvement Possible (MIP) - typically 3 years
☐ Medical Improvement Not Expected (MINE) - typically 5-7 years

Form Received:
☐ SSA-455 (Short Form / Mailer)
☐ SSA-454 (Long Form / Full CDR Report)

Current Benefits:
☐ Title II - SSDI
☐ Title XVI - SSI
☐ Both

Monthly Benefit Amount: $_______________

Original Date Disability Began: _________________
Original Approval Date: _________________

RESPONSE DEADLINE

IMPORTANT: Complete and return CDR forms within the deadline stated in the notice, typically 10-30 days. Failure to respond may result in benefit suspension.

Deadline Date: _________________
Extension Requested: ☐ Yes ☐ No
New Deadline (if extended): _________________

CDR LEGAL STANDARD

Medical Improvement Review Standard (MIRS):

Under 20 C.F.R. § 404.1594, benefits may be ceased only if:

1. Medical Improvement has occurred (improvement in symptoms, signs, or laboratory findings), AND
2. The improvement is related to ability to work, AND
3. Claimant can now engage in Substantial Gainful Activity (SGA)

OR an exception applies:
- Substantial evidence demonstrates ability to engage in SGA (Group I exceptions)
- Claimant failed to cooperate or whereabouts unknown (Group II exceptions)

SSA Must Prove:

☐ Comparison Point Decision (CPD) - the decision SSA uses as baseline
☐ Medical improvement since CPD
☐ Improvement related to ability to work
☐ Current ability to perform SGA

CURRENT MEDICAL CONDITIONS

Primary Disabling Conditions:

Has Your Condition Changed Since Disability Was Approved?

☐ Condition has worsened
Explain: _____________________________________________________________________________
_____________________________________________________________________________

☐ Condition remains the same
Explain: _____________________________________________________________________________
_____________________________________________________________________________

☐ Some improvement, but still disabled
Explain: _____________________________________________________________________________
_____________________________________________________________________________

☐ New conditions have developed
List new conditions:
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________

CURRENT MEDICAL TREATMENT

Treating Physicians/Providers:

Current Medications:

Recent Hospitalizations/Emergency Room Visits:

Other Treatments:

☐ Physical therapy - Frequency: _________________
☐ Occupational therapy - Frequency: _________________
☐ Mental health counseling - Frequency: _________________
☐ Pain management - Frequency: _________________
☐ Dialysis - Frequency: _________________
☐ Chemotherapy/Radiation - Frequency: _________________
☐ Other: _________________________________________________

FUNCTIONAL STATUS

Daily Activities:

What can you do now that you could not do when you were approved for disability?
_____________________________________________________________________________
_____________________________________________________________________________

What activities are still limited by your conditions?
_____________________________________________________________________________
_____________________________________________________________________________

Self-Care:

Household Activities:

Mobility:

☐ Walk without assistance
☐ Need cane/walker
☐ Use wheelchair
☐ Cannot walk more than _____ feet/blocks
☐ Cannot stand more than _____ minutes
☐ Cannot sit more than _____ minutes

Cognitive Function:

☐ No cognitive difficulties
☐ Memory problems
☐ Concentration difficulties
☐ Cannot follow complex instructions
☐ Get confused easily
☐ Need reminders for appointments/medications

WORK ACTIVITY

Have You Worked Since Your Disability Began?

☐ No work activity
☐ Yes - See details below

Work Activity Details:

If You Worked:

Was this work at the SGA level?
☐ No, earnings were below SGA
☐ Yes, but it was an Unsuccessful Work Attempt (UWA)
☐ Yes, but I received subsidies/special conditions
☐ Yes, but I was in Trial Work Period

Why did the work end (if applicable)?
☐ Condition prevented continuing
☐ Laid off/terminated for other reasons
☐ Still working
☐ Other: _________________________________________________

Special Work Conditions (if applicable):

☐ Extra supervision
☐ Reduced duties
☐ Flexible schedule
☐ Extra breaks
☐ Modified job duties
☐ Employer accommodations - Describe: _________________________________________________

CURRENT FUNCTIONAL LIMITATIONS

Physical Limitations:

In an 8-hour day, I can:
- Sit: ☐ Less than 2 hrs ☐ 2-4 hrs ☐ 4-6 hrs ☐ 6+ hrs
- Stand: ☐ Less than 2 hrs ☐ 2-4 hrs ☐ 4-6 hrs ☐ 6+ hrs
- Walk: ☐ Less than 2 hrs ☐ 2-4 hrs ☐ 4-6 hrs ☐ 6+ hrs

I can lift/carry:
☐ Less than 10 lbs ☐ 10 lbs ☐ 20 lbs ☐ 50 lbs

I have difficulty with:
☐ Bending ☐ Stooping ☐ Kneeling ☐ Crouching
☐ Climbing stairs ☐ Reaching ☐ Handling objects
☐ Other: _________________________________________________

Mental Limitations:

☐ Difficulty concentrating for extended periods
☐ Problems remembering things
☐ Difficulty following instructions
☐ Problems interacting with others
☐ Cannot handle stress
☐ Panic attacks/anxiety
☐ Depression affecting function
☐ Other: _________________________________________________

ARGUMENTS AGAINST CESSATION

Medical Improvement Has NOT Occurred Because:

☐ My condition has worsened since approval
Evidence: _____________________________________________________________________________

☐ My condition remains essentially the same
Evidence: _____________________________________________________________________________

☐ Any apparent improvement is not sustained
Evidence: _____________________________________________________________________________

☐ New conditions have developed that are equally or more disabling
Evidence: _____________________________________________________________________________

Even If Some Improvement, Still Disabled Because:

☐ I still cannot perform substantial gainful activity
☐ My limitations still prevent full-time work
☐ I still meet or equal a Listing
☐ I cannot perform past relevant work
☐ I cannot perform other work due to age, education, and RFC

EVIDENCE TO SUBMIT

Medical Records:

Medical Source Statements:

☐ Updated RFC from treating physician
☐ Letter from treating physician regarding disability
☐ Mental health provider statement

Other Evidence:

☐ Prescription records
☐ Hospitalization records
☐ Test results (labs, imaging)
☐ Third-party function reports
☐ Vocational evidence
☐ Other: _________________________________________________

IF BENEFITS ARE CEASED

Appeal Rights:

You have 60 days from the cessation notice to appeal (request reconsideration)

Continuation of Benefits During Appeal:

CRITICAL: If you request reconsideration within 10 days of the cessation notice, benefits may continue during the appeal.

☐ I request continuation of benefits during the appeal
☐ I understand that if the cessation is upheld, I may have to repay benefits received during the appeal

Appeal Levels:

1. Reconsideration (Disability Hearing in most states)
2. ALJ Hearing
3. Appeals Council
4. Federal Court

SUPPORTING STATEMENT

Please use this space to explain why your disability continues and why you cannot work:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

THIRD-PARTY CONTACT

Person who can describe your daily limitations:

Name: _________________________________________________
Relationship: _________________________________________________
Phone: _________________
Address: _________________________________________________

REPRESENTATIVE PAYEE INFORMATION (if applicable)

☐ I have a representative payee

Payee Name: _________________________________________________
Relationship: _________________________________________________
Phone: _________________
Address: _________________________________________________

ATTACHMENTS CHECKLIST

☐ Completed SSA-454 or SSA-455 form
☐ Current medication list
☐ Medical records since last review
☐ Treating physician statement(s)
☐ Medical source statement (RFC)
☐ Updated function report
☐ Third-party statement
☐ Hospitalizations/ER records
☐ Work activity documentation (if any)
☐ Other: _________________________________________________

CERTIFICATION

I certify that the information provided in this response is true and complete to the best of my knowledge. I understand that I must report any changes in my medical condition or work activity to the Social Security Administration.

Claimant Signature: _________________________________ Date: _________________

Representative Signature: _________________________________ Date: _________________

SUBMISSION INSTRUCTIONS

Return completed forms to:

☐ Local SSA Office:
_________________________________________________
_________________________________________________

☐ By Mail to address on notice:
_________________________________________________

☐ By Fax: _________________

Keep copies of everything you submit.

FOLLOW-UP

Date CDR Response Submitted: _________________
Method: ☐ In-person ☐ Mail ☐ Fax

Confirmation/Receipt: _________________

SSA Contact for Questions: _________________

Expected Timeline:
- Initial CDR decision: 30-90 days
- If cessation: 10 days to request continued benefits
- If cessation: 60 days to appeal

This response is submitted pursuant to the Continuing Disability Review provisions of 42 U.S.C. § 423(f) and the Medical Improvement Review Standard of 20 C.F.R. § 404.1594 and/or 20 C.F.R. § 416.994.