Form HA-510-OP1 Option to Accept an Earlier Hearing Waiver of Timely Wri

Form HA-510-OP1 (06-2017)
Social Security Administration
Office of Disability Adjudication and Review

Page 1 of 2
OMB No. 0960-0671

Option to Accept an Earlier Hearing
Waiver of Timely Written Notice of Hearing
In the case of :

Claim for:

(Claimant)

(Wage Earner) (Leave blank if same as above)

(Social Security Number)

I understand that the Social Security Administration (SSA) is required to send me a notice of hearing at least
75 days before the date set for the hearing. However, if a hearing time becomes available in less than 75
days, I want an option to accept that earlier hearing time. I understand that if I accept an earlier hearing time,
SSA will tell me the date and time of my hearing less than 75 days before the date my hearing will be held.
I waive my right to a notice of hearing postmarked at least 75 days before the date of the hearing. I wish to
have the option to accept a hearing time:
as soon as possible, or
at least 7 calendar days after SSA contacts me.
I must inform SSA about or submit all evidence known to me that relates to whether or not I am blind or
disabled. I must do this at least 5 business days prior to the date of hearing. I understand that the
administrative law judge may not accept evidence that I inform SSA about or submit less than 5 days prior to
the hearing, unless I provide a good reason.
If I am given the option to attend an earlier hearing and decline, I understand that it will not delay the
scheduling of my case, and SSA will send me a notice of hearing at least 75 days before the date of the
hearing. If I accept an earlier hearing time, and do not appear for that hearing, I understand that SSA may
dismiss my request for a hearing.
Claimant Signature:

Address:

Date:

Area Code and Telephone Number:

Form HA-510-OP1 (06-2017)

Page 2 of 2

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(b)(1), 205(d), and 1631(c) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from completing the hearing process.
See Revised Privacy Act Statement Attached

We will use the information to document your waiver of rights to receive the written Notice of Hearing. We
may also share your information for the following purposes, called routine uses:
1. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social
Security Administration (SSA) in the efficient administration of its programs; and
2. To student volunteers and other workers, who technically do not have the status of Federal
employees, when they are performing work for SSA as authorized by law, and they need access
to personally identifiable information in SSA records in order to perform their assigned Agency
functions.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person's eligibility for federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0005,
entitled Administrative Law Judge Working File on Claimant Cases and 60-0089, entitled Claims Folders
Systems. Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.
See Revised PRA Attached

Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to
answer these questions unless we display a valid Office of Management and Budget (OMB) control number.
We estimate that it will take about 5 minute to read the instructions, gather the facts, and answer the
questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not
the completed form.