DI 12095.135 Model Language SSI Notice of Planned Action - Noncompliance With Treatment Referral
Supplemental Security Income
Notice of Planned Action
Department of Health and Human Services
Social Security Administration
| || |
Social Security Number:
Your payments (or those of the individual named above) will be changed as follows:
Your payment will be stopped effective (date).
Under the law, a disabled person who is medically determined to be a drug addict or alcoholic must receive his supplemental security income payments through another person on his behalf. In addition, he must undergo any appropriate treatment for his condition as a drug addict or alcoholic, if such treatment is available, in order to be eligible for payments.
We informed you that the medical evidence in your claim shows that (drug addiction) (alcoholism) 1/ contributes to the finding that you are disabled. Therefore, your payments must be made to another person on your behalf. In addition, you must undergo any appropriate treatment for your condition as a (drug addict) (alcoholic) 1/, if such treatment is available, in order to be eligible for payments.
We contacted you and informed you that we have been advised that you are not complying with the treatment requirement, and we asked you to come to this office to discuss the matter, which you have not done.
Since you are not complying with the treatment requirement, the provisions of the law are not met and your payments will be stopped effective (date).
This infornation is also being sent to (name of representative payee).
1/Use term(s) that applies
We won't change your check if you appeal within 10 days after getting this notice.
TURN THIS OVER if you think we're wrong
YOUR RIGHT TO APPEAL
Do you think we're wrong? If so, you have the right to appeal. If you appeal, we'll review our decision. We'll change mistakes. Do you have other questions? If so, get in touch with us. Please bring this notice with you if you come to a Social Security office.
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days, you must have a good excuse.
APPEAL IN 10 DAYS TO KEEP GETTING YOUR SAME CHECK
We won't change your check if you appeal within 10 days after getting this notice. You'll keep getting your same check until we decide your appeal. If you lose your appeal, you might have to pay some or all of this money back.
HOW TO APPEAL
There are three different ways to appeal. You can pick the one you want. The people in our offices can explain how these appeals work. You can have a lawyer, friend, or someone else help you with your appeal.
Here are the three ways to appeal:
You can give us more facts to add to your file. Then we'll decide your case again. You don't meet with the person who decides your case.
You'll meet with the person who will decide your case. You can tell that person why you think you're right. You can give us more facts to help prove you're right. You can bring other people to help explain your case.
This is a meeting like an informal conference. Plus, we can make people come to help prove you're right. We can make them bring important papers about your case. We can do this even if they don't want to help you. You can question these people at your meeting.
To appeal, you must fill out a form at one of our offices It is called a Request for Reconsideration, SSA-561-U2. On the form, YOU PICK THE KIND OF APPEAL YOU WANT. We'll help you fill it out.
There are groups that can help you with your appeal. Some can give you a free lawyer. We can give you names of these groups.