REQUEST FOR RECONSIDERATION

Social Security Administration

FILING INFORMATION

CRITICAL DEADLINE: Request must be filed within 60 days of receiving the initial determination. SSA presumes receipt 5 days after the date on the notice unless proven otherwise.

Date of Initial Determination: _________________
Presumed Receipt Date: _________________
60-Day Deadline: _________________
Date of This Request: _________________

☐ Filed within 60 days
☐ Late filing - Good Cause statement attached (see Section below)

CLAIMANT INFORMATION

Claimant Name: _________________________________________________
Social Security Number: _____ - _____ - _________
Date of Birth: _________________
Address: _________________________________________________
City, State, ZIP: _________________________________________________
Phone Number: _________________
Email: _________________________________________________

Representative (if applicable):
Name: _________________________________________________
Firm: _________________________________________________
Phone: _________________________________________________
☐ Form SSA-1696 on file ☐ Form SSA-1696 attached

TYPE OF DETERMINATION BEING APPEALED

☐ Initial Disability Application Denial
☐ Cessation of Benefits (Continuing Disability Review)
☐ Overpayment Determination
☐ SSI Resource/Income Determination
☐ Other: _________________________________________________

Claim Type:
☐ Title II - SSDI
☐ Title XVI - SSI
☐ Both Title II and Title XVI

TYPE OF RECONSIDERATION REQUESTED

For Disability Cases (Non-Medical Cessation States):

☐ Case Review - File review only, no personal appearance
☐ Informal Conference - Opportunity to present case to decision-maker
☐ Formal Conference - Present witnesses, cross-examine SSA witnesses

For Medical Cessation Cases:

☐ Disability Hearing - Required in most states for medical cessation cases
(Conducted by Disability Hearing Officer)

For Non-Disability Issues:

☐ Case Review - Standard reconsideration

STATEMENT OF DISAGREEMENT

I disagree with the determination dated _________________ for the following reasons:

Primary Reasons for Appeal:

☐ SSA failed to properly evaluate my medical evidence
☐ SSA failed to consider all of my impairments
☐ The RFC assessment does not reflect my actual limitations
☐ SSA did not properly apply the treating physician rule
☐ My condition meets or equals a Listing
☐ SSA failed to consider the combined effect of my impairments
☐ New and material evidence is available
☐ SSA made factual errors
☐ SSA made legal errors in applying regulations
☐ Other: _________________________________________________

DETAILED EXPLANATION OF ERRORS

Error 1: _________________________________________________

SSA's Finding:
_____________________________________________________________________________
_____________________________________________________________________________

Why This Finding Is Incorrect:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Supporting Evidence:
_____________________________________________________________________________
_____________________________________________________________________________

Error 2: _________________________________________________

SSA's Finding:
_____________________________________________________________________________
_____________________________________________________________________________

Why This Finding Is Incorrect:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Supporting Evidence:
_____________________________________________________________________________
_____________________________________________________________________________

Error 3: _________________________________________________

SSA's Finding:
_____________________________________________________________________________
_____________________________________________________________________________

Why This Finding Is Incorrect:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Supporting Evidence:
_____________________________________________________________________________
_____________________________________________________________________________

MEDICAL CONDITION SUMMARY

Primary Disabling Conditions:

1. _________________________________________________
   - ICD-10 Code: _________
   - Diagnosing Physician: _________________________________________________
   - Date of Diagnosis: _________________

2. _________________________________________________
   - ICD-10 Code: _________
   - Diagnosing Physician: _________________________________________________
   - Date of Diagnosis: _________________

3. _________________________________________________
   - ICD-10 Code: _________
   - Diagnosing Physician: _________________________________________________
   - Date of Diagnosis: _________________

Relevant Listing(s) (20 C.F.R. Part 404, Subpart P, Appendix 1):

☐ Listing _________ : _________________________________________________
☐ Listing _________ : _________________________________________________
☐ Listing _________ : _________________________________________________

FUNCTIONAL LIMITATIONS

Physical Limitations:

Sitting: ☐ Normal ☐ Limited to _____ hours/day
Standing: ☐ Normal ☐ Limited to _____ hours/day
Walking: ☐ Normal ☐ Limited to _____ blocks/minutes
Lifting: ☐ Normal ☐ Limited to _____ pounds
Carrying: ☐ Normal ☐ Limited to _____ pounds

Other Physical Limitations:
☐ Cannot bend/stoop
☐ Cannot climb stairs
☐ Cannot reach overhead
☐ Requires assistive device: _________________________________________________
☐ Other: _________________________________________________

Mental Limitations:

☐ Difficulty concentrating for extended periods
☐ Memory problems affecting work ability
☐ Difficulty following instructions
☐ Problems interacting with others
☐ Cannot handle work stress
☐ Attendance problems due to symptoms
☐ Other: _________________________________________________

NEW EVIDENCE SUBMISSION

Medical Evidence Not Previously Considered:

New Medical Sources:

☐ Authorization forms (SSA-827) attached for new sources
☐ Medical records attached
☐ Medical source statements attached
☐ Additional evidence to be submitted by: _________________

CHANGES SINCE INITIAL APPLICATION

☐ Condition has worsened since initial application
☐ New diagnoses since initial application
☐ Hospitalization(s) since initial application
☐ New treatments/medications since initial application
☐ Surgery since initial application
☐ Other changes: _________________________________________________

Describe Changes:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

GOOD CAUSE FOR LATE FILING

(Complete only if filing after 60-day deadline)

☐ I did not receive the determination notice
☐ I received the notice late (after _____ days)
☐ Serious illness prevented timely filing
☐ Death in family prevented timely filing
☐ Important records were destroyed/lost
☐ I was misled by SSA
☐ I did not understand the appeal requirements
☐ Other circumstances beyond my control

Detailed Explanation:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Supporting Documentation:
☐ Medical records showing incapacity
☐ Death certificate
☐ Proof of mailing issues
☐ Other: _________________________________________________

REQUEST FOR CONTINUATION OF BENEFITS

(For Cessation Cases Only)

☐ I request continuation of benefits during reconsideration
(Must be filed within 10 days of cessation notice)

Understanding of Overpayment Risk:
☐ I understand that if the cessation is upheld, I may be required to repay benefits received during the appeal

ATTACHMENTS CHECKLIST

☐ Form SSA-561 (Request for Reconsideration)
☐ Form SSA-3441 (Disability Report - Appeal)
☐ Copy of initial determination being appealed
☐ Form SSA-827 (Authorization to Disclose Information)
☐ Form SSA-1696 (Appointment of Representative)
☐ Medical records
☐ Medical source statements
☐ Updated medication list
☐ Function report updates
☐ Third-party statements
☐ Other: _________________________________________________

CLAIMANT CERTIFICATION

I certify that the information provided in this request is true and correct to the best of my knowledge. I understand that making false statements may result in criminal penalties.

Claimant Signature: _________________________________ Date: _________________

Representative Signature: _________________________________ Date: _________________

SUBMISSION INSTRUCTIONS

Submit to:
Social Security Administration
[Local Field Office Address]
_________________________________________________
_________________________________________________

Alternative Submission Methods:

☐ In person at local SSA office
☐ By mail to address above
☐ Online at www.ssa.gov (if available)
☐ By fax to: _________________

Retain Copies: Keep copies of all documents submitted for your records.

Confirmation: Request a dated receipt or send by certified mail with return receipt requested.

WHAT TO EXPECT

1. Acknowledgment: SSA should acknowledge receipt within 2-4 weeks
2. Processing Time: Reconsideration typically takes 3-6 months
3. Additional Requests: SSA may request consultative examination
4. Decision: Written decision will be mailed
5. Next Appeal: If denied, you have 60 days to request ALJ hearing

This request is submitted pursuant to 20 C.F.R. § 404.907 et seq. and/or 20 C.F.R. § 416.1407 et seq.