Request for Reinstatement (Title XVI)

Mandatory Choice 1 of 4 (SSAH01)

Social Security Administration

Retirement, Survivors and Disability Insurance

Mandatory Choice 2 of 4 (SSAH10)

Social Security Administration

Supplemental Security Income

Mandatory Choice 3 of 4 (SSAH90)

Social Security Administration

Mandatory Choice 4 of 4 (SSAH89)

Social Security Administration

Medicare Prescription Drug Assistance

Important Information

<<F1>>

Claim Number: <<F1>>

<<F2>>

<<F1>>

<<F1>>

<<F2>>

Optional (SSAH74)

Dear <<F1>>

On <<F1>>, we talked with <<F2>> about expedited reinstatement of <<F3>> payments. We are sending you the enclosed "Request for Expedited Reinstatement of <<F4>>" and the accompanying "Supplement to the Request for Expedited Reinstatement" form we filled out based on <<F5>> statements. We are also sending you Form SSA-454 (Report of Continuing Disability Interview) to complete medical source and other information and Form SSA-827 (Authorization to Disclose Information to the Social Security Administration) for disclosure of information. We cannot decide if <<F6>> <<F7>> reinstatement without these completed forms.

What You Need To Do

• Sign and date the Request for Expedited Reinstatement

• Answer any circled questions on the Request for Expedited Reinstatement and the Supplement to the Request for Expedited Reinstatement

• Complete Form SSA-454 and Form SSA-827

• Sign and date the request form and any other accompanying forms that require a signature, in the "Signature" space

• Mail (or bring) the Request for Expedited Reinstatement and any accompanying forms to the Social Security office address shown above. A self-addressed envelope is enclosed for your convenience. Add your return address on the envelope and remember to place the correct amount of postage on it.

If We Don't Hear From You

It is important that you sign the Request for Expedited Reinstatement and any accompanying forms that require a signature and return them to us by <<F1>>. The sooner we get the signed request for reinstatement and other forms, the sooner we may be able to begin paying <<F2>> provisional (temporary) benefits while the reinstatement request is being decided. If you do not return the forms by the above date, you may lose benefits.

If You Do Not Want to File for Expedited Reinstatement

If you decide not to request expedited reinstatement but want to file a new initial application for <<F1>> benefits instead, then sign and return only the "Supplement to the Request for Expedited Reinstatement" (an application form) along with the SSA-454 and medical release forms to us by <<F2>>. If you decide to file a new application and return the required forms to us by this date, we will use <<F3>>, the date we first talked to you about expedited reinstatement, as the filing date of your application.

If You Have Any Questions

Mandatory Choice 1 of 3 (REF032)

For general information about SSI, visit our website at www.socialsecurity.gov on the Internet. There you will also find the law and regulations about SSI eligibility and SSI payment amounts.

For general questions about SSI or specific questions about <<F1>> case, you may call us toll-free at 1-800-772-1213 or call your local Social Security office at <<F2>>. If you call or visit our office, please bring this letter with you and ask for <<F3>>.

Mandatory Choice 2 of 3 (REF038)

For general information about Social Security we invite you to visit our website at www.socialsecurity.gov on the Internet. For general questions and specific questions about <<F1>> case, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at <<F2>> and ask for <<F3>>. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY/TDD number <<F4>>. If you do call or visit an office, please have this letter with you. It will help us answer your questions.

Mandatory Choice 3 of 3 (REF061)

We invite you to visit our web site at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local office at <<F1>>. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

<<F2>>

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 may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

<<F1>>

<<F2>>

<<F3>>

Optional (ENC096)

Enclosure(s):

Optional (ENC095)

<<F1>>