RV You must use forms provided by the SSA. You can t-S-J obtain them at your local SSA Field Office or by calling the SSA hotline at 800-772-1213, Monday through Friday (except holidays), from 7 a.m. to 7 p.m. If you are deaf or hard of hearing, TTY service representatives are available at the same times at 800-325-0778. You can also download many necessary forms from the Social Security Administration website at www.ssa.gov.
1 If you've been self-employed (earned income that does not result from being an employee of someone else) within the last two years, check "yes" and indicate the dates you worked and your monthly earnings. Otherwise, check "no."
2 Indicate if you think your condition is better, the same or worse than when you started receiving benefits or at the time of your previous CDR.
3 If your doctor told you during the last two years that you could return to work, check "yes." Otherwise, check "no."
4 If you attended any school or work training program during the last two years, check "yes." Otherwise, check "no."
5 If you are interested in receiving rehabilitation or other services that could help you get back to work, check "yes." Otherwise, check "no."
6 If you have been hospitalized or had any surgery during the last two years, check "yes" and give the reasons for the hospitalization or surgery and the dates. Otherwise, check "no."
7 If you have visited a doctor or clinic for your condition during the last two years, check "yes" and
Sample Notice of Continuing Disability Review (Page 1)
Office of Disability Operations 1500 Woodlawn Drive Baltimore, Maryland 21241
Date: June 14, 20xx Claim Number: 000-00-0000
We must regularly review the cases of people getting disability benefits to make sure they are still disabled under our rules. It is time for us to review your case. This letter explains how we plan to start our review of your case.
Please complete the form enclosed with this letter. Answer all the questions on the form because they are very important. They ask about your health problems and any work you did within the last 2 years.
We have enclosed an envelope for you to use. If there is no envelope with this letter, please send the signed form to us at the address shown above.
If We Do Not Hear From You
You should return the form within 10 days after you receive it. If we do not hear from you in that time, we will contact you again.
If you don't give us the information we need or tell us why you cannot give us the information, we may stop your benefits. Before we stop your benefits, we will send you another letter to tell you what we plan to do.
When We Receive the Completed Form
• If we need more information we will call you. If you do not have a telephone, please give a number where we can leave a message for you.
• The information you give us now will help us decide when we should do a full medical review of your case. We will let you know within 90 days after we receive the completed form whether or not we need to do a full medical review now.
If we decide to do a full medical review of your case:
• You can give us any information which you believe shows that you are still disabled, such as medical reports and letters from your doctors about your health.
• We will look at all the information in your case, including the new information you give us.
• We may find that you are no longer disabled under our rules and your payments will stop. If this happens you can appeal our decision. You can also ask us to continue to pay benefits while you appeal.
Sample Notice of Continuing Disability Review (Page 2)
Do you want to work but worry about losing your payments or Medicare before you can support yourself? We want to help you go to work when you are ready. But, work and earnings can affect your benefits. Your local Social Security office can tell you more about how work and earnings can affect your benefits.
If you have any questions, you may call us at 800-772-1213, or call your Social Security Office at 000-000-0000. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at: 12345 Main Street New York, NY 10000 If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you should call ahead to make an appointment. This will help us serve you more quickly.
JamceL. Warden Janice L. Warden
Deputy Commissioner for Operations
Enclosures: SSA-455 Return Envelope
I'ORM APPROVED OMB NO.0960 0511
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