HA-L83 - Revised Version

SOCIAL SECURITY ADMINISTRATION
Refer To:
[ClaimantFirstName] [ClaimantMiddleName]
[ClaimantLastName] [ClaimantSuffix]
BNC#: [BeneficiaryNoticeControl]

Office of Hearings Operations
[LocalOfficeCompleteAddress]
Tel: [LocalOfficePhone] / Fax:
[LocalOfficeFax]
[Today’s Date]

[OBOFirstName][OBOMiddleName][OBOLastName][OBOSuffix] on behalf of
[ClaimantFirstName][ClaimantMiddleName][ClaimantLastName][ClaimantSuffix]
[OBOCompleteAddress]

[ClaimantFirstName][ClaimantMiddleName][ClaimantLastName][ClaimantSuffix]
[ClaimantAddress]

NOTICE OF HEARING – DECEASED CLAIMANT
Based on the Substitution of Party form you submitted, I will continue processing
[ClaimantFullName]’s appeal with you as the substitute party. You and your representative, if
you have one, should complete the Acknowledgement of Notice of Hearing and return it as soon
as possible.
This notice may contain forms requesting information about [ClaimantFullName]. If you can
provide any of the requested information or have additional information related to this case,
please provide the information to us when you return the Acknowledgement of Notice of
Hearing.
I have scheduled your hearing for:
Day:

[HearingDay]

Date:

[HearingDate]

Time: [HearingTime]
[HearingTimeZone]

Please bring this notice with you.
Form HA-83 (01-2022)
ClaimantRepresentative

Suspect Social Security Fraud?
Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline
at 1-800-269-0271 (TTY 1-866-501-2101).
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If you would like to call a witness to testify at the hearing, contact this office at
[LocalOfficePhone] to arrange for them to participate in your hearing.

You are scheduled to attend your hearing by audio using a telephone. On the date and time listed
above, I will call you at this telephone number: [ClaimantPhoneNumber]. If this number is not
the correct telephone number, please call this office immediately at [LocalOfficePhone].
On the day of the hearing, we will call you at the telephone number you provided:
• If you provided a cell phone number for the hearing, the incoming call will display as
“Catonsville, MD.”
• If you provided a landline phone number, your caller ID will display as “SSA U.S.
Govt.”
• If you do not receive a telephone call or if you experience technical difficulties with
receiving the telephone call, please call this office at [LocalOfficePhone].

You are scheduled to attend your hearing by online video using Microsoft Teams. Before the
hearing, you will receive an email with a link to access the hearing by online video on the date
and time listed above. If you do not receive an email with a link to access the hearing at least a
day before the hearing, please call this office at [LocalOfficePhone].
On the day of the hearing, if you have difficulty connecting by online video, please call this
office at [LocalOfficePhone]. As a reminder, you cannot make a video recording, or take
photographs or screenshots, of the hearing. You may make an audio recording only if you
request to do so and I grant your request.

Room: [HearingRoom]

Address:

[HearingLocationCompleteAddress]

Room: [ClaimantHearing Address:
Room]

[ClaimantHearingLocationCompleteAddress]

You are scheduled to attend your hearing by agency video using our video equipment at one of
our locations. You must go to the location shown above for the hearing, and I will be at a
different location. We will be able to see, hear, and speak to each other during the hearing. I will
also be able to see, hear, and speak to anyone else who participates in the hearing, including your
representative (if you have one), a friend, or a family member. A technician will be at your
location to operate the video equipment and provide any other help you may need.

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You will receive this document in both a standard print and Braille version. standard print version and on
a compact disc in Microsoft Word format. standard print version
and on an audio compact disc. standard print and large print
version. You will receive each version separately.

It Is Important That You and Your Child Attend Your
Hearing

I have set aside this time for you to tell me about your case. If you and your
representative do not attend the hearing, I may dismiss your request for hearing unless
I find that you had a good reason for not attending. I may dismiss your request for hearing
without giving you further notice.
Your child should be present for the hearing. You must bring
someone to care for your child, as your child may not need to be present for the entire
hearing.

You must bring a valid current picture identification (ID) to your hearing. Examples of
acceptable picture ID include a:
•

U.S. State driver’s license.

•

U.S. State-issued identity card.

•

U.S. passport.

•

U.S. military ID/dependent military ID.

•

Native American Tribal ID.

If you do not have any of these forms of ID, please bring another form of picture ID with you.
A valid picture ID is also required for your representative (if you have one), and anyone
accompanying you to the hearing. If you or anyone accompanying you to the hearing does not
have a picture ID, please call our office at [LocalOfficePhone] so that we can arrange access
to the building where your hearing is being held.

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Complete the Enclosed Form
Please complete and return to us the enclosed acknowledgement form using the enclosed
envelope as soon as possible. We sent your representative a copy of the
acknowledgement form. Your representative should also return their copy of the form.

If You Cannot Attend Your Scheduled Hearing

You can object to the time of your hearing, the place
of your hearing, or both. If you cannot attend your hearing at the scheduled time and place, please call this office
immediately at [LocalOfficePhone] to make an objection and request a change. You must also
submit your request in writing and tell us why you want us to change the time of your hearing
, the place of your hearing, or both.
If you object to the time or place of
the hearing, you must notify us in writing at the earliest possible opportunity, but not later
than 5 days before the hearing or 30 days after receiving notice of the hearing, whichever is
earlier. We assume you received this notice 5 days after the date on the top of the notice
unless you show us that you did not get it within the 5-day period. If you miss the deadline for
objecting, please tell us why you missed the deadline. I will extend the deadline if I find that
you have good cause, as defined in our regulations, for the delay.
If I find that you have a good reason for objecting and requesting a change, we will reschedule
your hearing and will send you another notice at least 20 days before the date of the hearing.
If I find that you do not have a good reason for objecting and requesting a change, you must
attend at the time and place shown
above or I may dismiss your request for hearing.

If You No Longer Want to Attend Your Hearing by Online Video Using Microsoft Teams
If you no longer want to attend your hearing by online video using Microsoft Teams, please
let us know as soon as possible, before the time set for the hearing, by calling
[LocalOfficePhone]. If you tell us that you no longer want to attend by online video, we will
reschedule your hearing so that you can attend in a different way. Please note that we may
need to change the date and time of your hearing.

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A Representative Could Help With Your Appeal
You have the right to be represented by an attorney or non-attorney. You are not required to
have a representative. If you have a representative, we will work with that person just as we
would work with you. If you want a representative, you should find one quickly so that person
can start preparing your case. If you get a representative, you should show this notice to your
representative. For more information about representation, including the fees a representative
may charge, visit www.ssa.gov/representation/ on the Internet.

Submitting More Evidence and Reviewing Your File
You must inform us about or submit all evidence known to you that relates to whether or not
you are blind or disabled. Your representative must help you submit
information and evidence to us. If you know about or have more evidence, such as
recent medical records, reports, or evaluations, you must inform me about it or give it to
me no later than 5 business days before the date of your hearing. If you miss this
deadline, I may not consider the evidence when I decide your case.
If you miss the deadline to inform me about or submit evidence, I will accept the evidence if I
have not yet issued a decision and you missed the deadline because:
1. Our action misled you.
2. You had a physical, mental, educational, or linguistic limitation that prevented you
from informing me about or submitting the evidence earlier.
3. Some other unusual, unexpected, or unavoidable circumstance beyond your control
prevented you from informing me about or submitting the evidence earlier.
If you want to review your file before the date of your hearing, please call this office at
[LocalOfficePhone] to make arrangements to do so. If you have a
representative, they may be able to access your file electronically.

Issues Language
1.
2.
3.
4.
5.
6.
7.
8.
9.

If Claim Type=DIB, BIC=HA
elseif Claim Type: SSI=DI or DS and BIC=null
elseif Claim Type=DIB&SSI (SSI=AI/AS/DI/DS/BI/BS)
elseif Claim Type=DWB
elseif Claim Type=Child SSI
elseif Claim Type=Adult CDR DIB
elseif Claim Type=Adult CDR DI
elseif Claim Type=Adult CDR DIB/DI
elseif Claim Type=Adult CDR DWB
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10.
11.
12.
13.
14.
15.
16.

elseif Claim Type=Adult CDR DWB/DI
elseif Claim Type=Adult CDR DWB/DIB/DI
elseif Claim Type=Adult CDR CDB(CDBR/CDBD)
elseif Claim Type=Adult CDR CDB(CDBR/CDBD)/DI
elseif Claim Type=Adult CDR CDB(CDBR/CDBD)/DIB/DI
elseif Claim Type=SSI Child's CDR (BC/DC)
elseif Claim Type=DI (Disabled Individual) or BI (Blind Individual) (CDR type=NOT Null and Issue
Indicator=A18 (Age 18 Redetermination CDR (relevant only on Title XVI)))
17. elseif Claim Type=General Hearing any Claim Type:
a. if Overpayment=true, if Title II and Overpayment Only=true (Issue Indicator=O
(Overpayment))
b. if Title II and Waiver of Overpayment Only=true (Issue Indicator=W (Waiver Only
(overpayment issue not disputing amount or cause, non-disability)))
c. if Title II and Overpayment Only=true and Waiver of Overpayment Only=true (Issue
Indicator=OW (Overpayment with Waiver Request))
d. if Title XVI and Overpayment Only=true (Issue Indicator=O (Overpayment)
e. if Title XVI and Waiver of Overpayment Only=true (Issue Indicator= W (Waiver Only
(overpayment issue not disputing amount or cause, non-disability)))
f. if Title XVI and Overpayment Only=true and Waiver of Overpayment Only=true (Issue
Indicator=OW (Overpayment with Waiver Request))
g. if Title II & Title XVI and Overpayment Only=true (Issue Indicator=O (Overpayment)
h. if Title II & Title XVI and Waiver of Overpayment Only=true (Issue Indicator= W (Waiver
Only (overpayment issue not disputing amount or cause, non-disability)))
i. if Title II & Title XVI and Overpayment Only=true and Waiver of Overpayment Only=true
(Issue Indicator=OW (Overpayment with Waiver Request))
j. if Title II Child's Benefits (Issue Indicator= R - Relationship Factors- paternity/marriage
(Non-disability, relevant only on Title II); BIC=C (all C BIC values))
k. if Title II Widows/Widower's Benefits (Issue Indicator= R - Relationship Factorspaternity/marriage (Non-disability, relevant only on Title II); BIC=W (all W BIC values))
l. if Title II Wife's/Husband Benefits (Issue Indicator= R - Relationship Factorspaternity/marriage (Non-disability, relevant only on Title II))
i. if Wife; BIC=BK, BL, B2, B3, B5, B7, (Remarried Widows=D4, D9, DA, DL, DN)>
ii. elseif Divorced Wife; BIC=BN, BP, BQ, B9, DV, DW, DY, D7
iii. elseif Husband; BIC=BW, BY, (Remarried Widowers=DP, DQ, DR, DT, D5)
iv. elseif Divorced Husband; BIC=DC, DM, DS, DX, DZ
m. if Title XVI Non-Disability Issue (Issue Indicator = EI (Excess Income/Resources/Living
Arrangements (non-disability, relevant only on Title XVI)))
18. elseif Claim Type=DWB (Disabled Widow(er)'s Benefits)/DI (Disabled Individual)
19. elseif Claim Type=DWB (Disabled Widow(er)'s Benefits)/DIB (Disability Insurance Benefits)
20. elseif Claim Type=DWB (Disabled Widow(er)'s Benefits)/DIB (Disability Insurance Benefits)/DI
(Disabled Individual)
21. elseif Straight CDB=CDBR or CDBD
22. elseif Claim Type=CDB(CDBD/CDBR) (Child's Insurance Benefits)/DI (Disabled Individual)
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23. elseif Claim Type=CDB(CDBD and CDBR) (Child’s Insurance Benefits)/DI (Disabled Individual)
24. elseif Claim Type=CDB(CDBD/CDBR) (Child's Insurance Benefits)/DIB (Disability Insurance
Benefits)
25. elseif Claim Type=CDB(CDBD and CDBR) (Child’s Insurance Benefits)/DIB (Disability Insurance
Benefits)
26. elseif Claim Type=CDB(CDBD/CDBR) (Child's Insurance Benefits)/DIB (Disability Insurance
Benefits)/DI (Disabled Individual)
27. if no canned language and text in Issues I Will Consider textbox=true
28. if Claim Type=straight MQGE (Medicare Qualified Government Employment)
29. if Claim Type=MQGE (Medicare Qualified Government Employment)/DWB (Disabled
Widow(er)'s Benefits) (Issue Indicator=D (Disability))
30. if Claim Type=MQGE (Medicare Qualified Government Employment)/DWB (Disabled
Widow(er)'s Benefits)/SSI (Supplemental Security Income) (Issue Indicator=D (Disability))
31. if Claim Type=MQGE (Medicare Qualified Government Employment)/CDB (Child's Insurance
Benefits)
32. if Claim Type=MQGE (Medicare Qualified Government Employment)/DIB (Disability Insurance
Benefits)
33. if Claim Type=MQGE (Medicare Qualified Government Employment)/DIB (Disability Insurance
Benefits)/DWB (Disabled Widow(er)'s Benefits)
34. if Claim Type=MQGE (Medicare Qualified Government Employment)/DIB (Disability Insurance
Benefits)/CDB (Child's Insurance Benefits)
35. if Claim Type=MQGE (Medicare Qualified Government Employment)/DIB (Disability Insurance
Benefits)/SSI (Supplemental Security Income)
36. if Claim Type=MQGE (Medicare Qualified Government Employment)/DIB (Disability Insurance
Benefits)/SSI (Supplemental Security Income)/DWB (Disabled Widow(er)'s Benefits)
37. if Claim Type=MQGE (Medicare Qualified Government Employment)/SSI (Supplemental Security
Income)
38. if Claim Type=MQGE (Medicare Qualified Government Employment)/SSI (Supplemental Security
Income)/CDB (Child's Insurance Benefits)
39. if Claim Type=MQGE (Medicare Qualified Government Employment)/SSI (Supplemental Security
Income)/CDB (Child's Insurance Benefits)/DIB (Disability Insurance Benefits)

More About the Issues

[More About the Issues]

If I find that you have been disabled, I will also consider whether your disability continues
through the date of the decision or whether your condition(s) has improved.

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If I find that you are disabled and that you have a substance use disorder (drug, alcohol, or
both), I will also decide whether it is a contributing factor material to the determination of
disability. This materiality determination means I will decide whether you would be disabled
if you were not using drugs or alcohol. If drug addiction or alcoholism is a contributing factor
material to the determination of your disability, I will find you not disabled under Sections
223(d)(2), or 1614(a)(3), or 223(d)(2) and 1614(a)(3) of the Social Security Act.

Remarks
I may ask a Vocational Expert, a Medical Expert, or both to attend your hearing and answer
questions. If I ask an expert to attend your hearing, I will include that information below, or I
will send you an Amended Notice of Hearing prior to the date of your hearing.

A vocational expert will attend the hearing in-personby audioby agency videoby online video. The vocational expert’s resume will be added to your file
before your hearing, generally 20 days before the hearing.
A medical expert will attend the hearing in-personby audioby agency videoby online video. The medical expert’s resume will be added to your file before
your hearing, generally 20 days before the hearing.
A second medical expert will attend the hearing in-personby audioby agency videoby online video. The medical expert’s resume will be added to your file before
your hearing, generally 20 days before the hearing.
A third medical expert will attend the hearing in-personby audioby agency videoby online video. The medical expert’s resume will be added to your file before
your hearing, generally 20 days before the hearing.
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A fourth medical expert will attend the hearing in-personby audioby agency videoby online video. The medical expert’s resume will be added to your file before
your hearing, generally 20 days before the hearing.
A fifth medical expert will attend the hearing in-personby audioby agency videoby online video. The medical expert’s resume will be added to your file before
your hearing, generally 20 days before the hearing.

[Personalized Remarks related to expert(s)]

If You Object to the Issues
If you object to the issues or remarks listed above, you must tell me that and explain why in
writing. You must tell me as soon as possible, but not later than 5 business days before the
date of the hearing. If you miss this deadline, I will consider your objection(s) if you show
that you meet one of the exceptions set forth in our regulations.

Your Right to Request a Subpoena
In general, you must prove that you are blind or disabled. If you cannot get evidence that you
reasonably need to present your case fully, I may be able to help you by issuing a legal
document called a subpoena. A subpoena may require a person to submit documents or testify
at your hearing.
If you want to ask me to issue a subpoena, you must tell me that in writing as soon as
possible. I must receive your subpoena request no later than 10 business days before your
hearing, unless you show that you meet one of the exceptions set forth in our regulations. I
will review your request and may issue a subpoena if reasonably necessary for full
presentation of your case. In your request, please tell me:
•

What documents you need or who the witnesses are;

•

The location of the documents or witnesses;

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The important facts you expect the documents or witnesses to prove; and

• Why you cannot prove these facts without a subpoena.

What Happens at the Hearing?
•

I will ask you and any other witnesses to take an oath or to affirm that the testimony is
true.

•

You will have a chance to testify and tell me about your case.

•

You and your representative (if you have one) may review submitted documents,
present and question witnesses, state your case, and make statements about the facts
and law. If you want to submit a written statement before your hearing, you must give
me a copy and give a copy to each party no later than 5 business days before the date
of your hearing. If you miss this deadline, you may still submit a written statement
before your hearing if you show that you meet one of the exceptions set forth in our
regulations. You may also submit a written statement after the hearing.

•

I will ask you and any other witnesses questions that will help me make a decision in
your case.

We will make an audio recording of the hearing. We do not record the video portion of
any of our agency video or online video hearings.

•

Travel Expenses
We may pay certain travel expenses when you, your representative (if you have one), or
needed witnesses must travel more than 75 miles one-way to the hearing. We have enclosed
an information sheet that tells you about our rules for paying travel expenses. Please call this
office at [LocalOfficePhone] if you want more information.

The Decision
After the hearing, I will issue a written decision and mail it to you. The decision will explain
my findings of fact and conclusions of law. I will base my decision on all the evidence of
record, including the testimony at your hearing.

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If You Have Any Questions
If you have any questions, please call [LocalOfficePhone] or write this office. For your
convenience, our address is on the first page of this notice.

Sincerely,

[ALJFullName]
Administrative Law Judge

Enclosures:
Form HA-L23 (Restriction Reminder)
SSA Publication No. 05-10075 (Your Right To Representation)
Form HA-504 (Acknowledgement of Receipt of
Notice of Hearing)
Form HA-504-OP1 (Acknowledgement of Receipt of Notice of Hearing)
Form HA-504-OP2 (Acknowledgement of Receipt of Notice of
Hearing)

Enclosures:
Form HA-L23 (Restriction Reminder)
Form HA-504 (Acknowledgement of Receipt of
Notice of Hearing)
Form HA-504-OP1 (Acknowledgement of Receipt of Notice of Hearing)
Form HA-504-OP2 (Acknowledgement of Receipt of Notice of
Hearing)

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Enclosures:
Form HA-L23 (Restriction Reminder)
Form HA-L23-SP (Restriction Reminder – Spanish)
Form HA-83 (Notice of Hearing)
Formulario HA-83-SP (Aviso de audiencia - español)

Formulario HA-504-SP (Acuse de recibo de aviso de audiencia)
Form HA-504 (Acknowledgement of Receipt of Notice of Hearing)

Formulario HA-504-OP1-SP (Acuse de recibo de aviso de audiencia)
Form HA-504-OP1 (Acknowledgement of Receipt of Notice of Hearing)

Formulario HA-504-OP2-SP (Acuse de recibo de aviso de audiencia)
Form HA-504-OP2 (Acknowledgement of Receipt of Notice of Hearing)

cc:
[RepFirstName][RepMiddleName][RepLastName][RepSuffix]
[RepFirm]
[RepCompleteAddress]

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When we can pay travel expenses
If you must travel more than 75 miles one-way from your home or office to attend the hearing,
we may pay certain expenses. The following rules apply:
•

We may pay expenses such as the cost of a bus ticket or expenses for driving your car.

•

In certain circumstances, you may need meals, lodging, or taxicabs. The Administrative Law
Judge (ALJ) must approve these unusual travel costs before the hearing unless the costs
were unexpected or unavoidable.

•

The ALJ may also approve payment of travel expenses for your representative and any
witnesses the ALJ determines are needed at the hearing.

•

You must submit a written request for payment of travel expenses other than meals, lodging,
or taxicabs to the ALJ at the time of the hearing or as soon as possible after the hearing. List
what you spent and include supporting receipts. If you requested a change in the scheduled
location of the hearing to a location farther from your residence, we cannot pay you for any
additional travel expenses.

•

If you need money for travel costs in advance, you should tell the ALJ as soon as possible
before the hearing. We can make an advance payment only if you show that without it you
would not have the funds to travel to or from the hearing.

•

If you receive travel money in advance, you must give the ALJ an itemized list of your actual
travel expenses and receipts within 20 days after your hearing.

•

If we gave you an advance payment that is more than the amount you are due for travel
expenses, you must pay back the difference within 20 days after we tell you how much you
owe us.

•

If we reimburse you for travel expenses, we follow the rules in the Code of Federal
Regulations and apply the same rates and conditions of payment that govern travel expenses
for Federal employees. Our determination on travel expense reimbursement is final and not
subject to further review. 41 CFR Chapter 301 and 20 CFR 404.999a-999d
20 CFR 416.1495-149920 CFR
404.999a-999d, 416.1495-1499.

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Privacy Act Statement
Collection and Use of Personal Information
Sections 201(j), 1631(h), and 1817(i) of the Social Security Act, as amended, and 20 CFR
404.999(d) and 416.1499 allow us to collect this information, which we will use to make a
determination on your request for advance payment and/or reimbursement of allowable travel
expenses. Providing this information is voluntary, but not providing all or part of the
information may prevent us from making an accurate and timely decision on your request for
advance payment and/or reimbursement of allowable travel expenses. As law permits, we may
use and share the information you submit, including with other Federal agencies, State and local
tax authorities, contractors, and others, as outlined in the routine uses within System of Records
Notice(s) (SORN) 60-0089, 60-0231, and 60-0320; available at www.ssa.gov/privacy. The
information you submit may also be used in computer matching programs to establish or verify
eligibility for Federal benefit programs and to recoup debts under these programs.

Issues I will consider Language:

Issues I Will Consider
The hearing concerns your application of [Title II Application Date], for a Period of Disability
and Disability Insurance Benefits under sections 216(i) and 223(a) of the Social Security Act
(the Act). I will consider whether you are disabled under sections 216(i) and 223(d) of the
Act.
Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted 12 continuous months, can be expected to last for 12 continuous months, or
can be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:

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•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and work
experience.

I will also consider whether you have enough earnings under Social Security to be insured for
a Period of Disability and Disability Insurance Benefits. If you do, I must decide whether you
became disabled while you were insured.
Our records indicate that your date last insured is [DLI Date]. If this is
correct, I must decide whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B and Subpart P.
[Issues I Will Consider Textbox]

Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title XVI Application Date], for Supplemental
Security Income (SSI) under section 1614(a)(3) of the Social Security Act (the Act). I will
consider whether you are disabled under section 1614(a)(3) of the Act.
Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted 12 continuous months, can be expected to last 12 continuous months, or
can be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:

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•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and work
experience.

Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 416, Subpart I.
[Issues I Will Consider Textbox]

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Issues I Will Consider
The hearing concerns your application of [Title II Application Date], for a Period of Disability
and Disability Insurance Benefits under sections 216(i) and 223(a) of the Social Security Act
(the Act). The hearing also concerns your application of [Title XVI Application Date], for
Supplemental Security Income (SSI). I will consider whether you are disabled under section
216(i), section 223(d), and section 1614(a)(3) of the Act.
Under the Act, I will find you disabled for those benefits or SSI if you have a physical or
mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted 12 continuous months, can be expected to last 12 continuous months, or
can be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
•

Any work you have done after your condition(s) began;

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ClaimantRepresentative

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•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and work
experience.

I will also consider whether you have enough earnings under Social Security to be insured for
a Period of Disability and Disability Insurance Benefits. If you do, I must decide whether you
became disabled while you were insured.
Our records indicate that your date last insured is [DLI Date]. If this is
correct, I must decide whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B, Subpart P and Part 416, Subpart I.
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275
Issues I Will Consider
The hearing concerns your application of [Title II Application Date], for Disabled Widow's
Insurance Benefits based upon disability under section 202(e)(f) of the Social Security Act (Act). To
decide your case, I will consider whether:
•

The deceased had enough earnings under Social Security to be fully insured;

•

You qualify as his surviving divorced wifehis widow her widowerher surviving divorced husband;

•

You are age 50 or older;

•

You have a disability as defined in the Act; and

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•

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Your disability began on or before [Prescribed Period End Date], the end of a special
period set by law.

This period begins with the later of:
•

The month of the worker’s death; or

•

The last month you were entitled to a survivor’s benefit on the worker’s record.

This period ends with the earlier of:
•

The month before you turn age 60; or

•

7 years after the period began.

Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted 12 continuous months, can be expected to last for 12 continuous months, or
can be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and work
experience.

Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III, Part
404, Subpart B and Subpart P.
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Issues I Will Consider
The hearing concerns your application of [Title XVI Application Date], for Supplemental
Security Income (SSI). I will consider whether you are disabled under section 1614(a)(3)(C)
of the Social Security Act (the Act).
Under the Act, I will find you disabled if you have a physical or mental condition(s) and:
•

You are not working;

•

You have a condition(s) that causes marked and severe functional limitations; and

•

Your condition(s) has lasted 12 continuous months, can be expected to last 12
continuous months, or can be expected to result in death.

I will follow a step-by-step process to decide if you are disabled. I will stop the process at the
first step I can make a decision. The steps in this process look at:
• Any work you have may have done after your condition(s) began;
• The severity of your condition(s); and
• Whether your condition(s) meets or medically equals the requirements of a listed
impairment in Appendix 1 of Subpart P of our regulations or functionally equals the
listings.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 416, Subpart I.
[ClaimantFullName]should be present at this hearing so I can
consider the case fully.
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Issues I Will Consider
I will decide whether your disability has ended. To decide this issue, I will apply the standard
stated in section 223(f) of the Social Security Act. I will consider:

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•

Whether there has been any medical improvement relating to your ability to work
since we last found you disabled; and

•

Whether one of the exceptions to medical improvement stated in the Act and our
regulations applies.

Our regulations explain the rules for deciding whether you are still disabled and, if not, when
your disability ended. These rules are in the Code of Federal Regulations, Title 20, Chapter
III, Part 404, Subpart P.
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Issues I Will Consider
I will decide whether you continue to be disabled. To decide this issue, I will apply the
standard stated in section 1614(a)(4) of the Social Security Act. I will consider:
•

Whether there has been any medical improvement relating to your ability to work
since we last found you disabled; and

•

Whether one of the exceptions to medical improvement stated in the Act and our
regulations applies.

In addition, if I decide that your disability ended, I will also determine whether you have
again become disabled since then.
Our regulations explain the rules for deciding whether you are still disabled and, if not, when
your disability ended. These rules are in the Code of Federal Regulations, Title 20, Chapter
III, Part 416, Subpart I.
[Issues I Will Consider Textbox]
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Issues I Will Consider
I will decide whether you continue to be disabled. To decide this issue, I will apply the
standard stated in sections 223(f) and 1614(a)(4) of the Social Security Act. I will consider:
•

Whether there has been any medical improvement relating to your ability to work
since we last found you disabled; and

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[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]
•

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Whether one of the exceptions to medical improvement stated in the Act and our
regulations applies.

In addition, if I decide that your disability ended, I will also determine whether you have
again become disabled since then.
Our regulations explain the rules for deciding whether you are still disabled and, if not, when
your disability ended. These rules are in the Code of Federal Regulations, Title 20, Chapter
III, Part 404, Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]
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Issues I Will Consider
I will decide whether your disability has ended. To decide this issue, I will apply the standard
stated in section 223(f) of the Social Security Act. I will consider:
•

Whether there has been any medical improvement relating to your ability to work
since we last found you disabled; and

•

Whether one of the exceptions to medical improvement stated in the Act and our
regulations applies.

Our regulations explain the rules for deciding whether you are still disabled and, if not, when
your disability ended. These rules are in the Code of Federal Regulations, Title 20, Chapter
III, Part 404, Subpart P.
[Issues I Will Consider Textbox]
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Issues I Will Consider
I will decide whether you continue to be disabled. To decide this issue, I will apply the
standard stated in sections 223(f) and 1614(a)(4) of the Social Security Act. I will consider:
•

Whether there has been any medical improvement relating to your ability to work
since we last found you disabled; and

•

Whether one of the exceptions to medical improvement stated in the Act and our
regulations applies.

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ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

In addition, if I decide that your disability ended, I will also determine whether you have
again become disabled since then.
Our regulations explain the rules for deciding whether you are still disabled and, if not, when
your disability ended. These rules are in the Code of Federal Regulations, Title 20, Chapter
III, Part 404, Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]
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Issues I Will Consider
I will decide whether you continue to be disabled. To decide this issue, I will apply the
standard stated in sections 223(f) and 1614(a)(4) of the Social Security Act. I will consider:
•

Whether there has been any medical improvement relating to your ability to work
since we last found you disabled; and

•

Whether one of the exceptions to medical improvement stated in the Act and our
regulations applies.

In addition, if I decide that your disability ended, I will also determine whether you have
again become disabled since then.
Our regulations explain the rules for deciding whether you are still disabled and, if not, when
your disability ended. These rules are in the Code of Federal Regulations, Title 20, Chapter
III, Part 404, Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]
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Issues I Will Consider
I will decide whether your disability has ended. To decide this issue, I will apply the standard
stated in section 223(f) of the Social Security Act. I will consider:
•

Whether there has been any medical improvement relating to your ability to work
since we last found you disabled; and

•

Whether one of the exceptions to medical improvement stated in the Act and our
regulations applies.

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ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

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Our regulations explain the rules for deciding whether you are still disabled and, if not, when
your disability ended. These rules are in the Code of Federal Regulations, Title 20, Chapter
III, Part 404, Subpart P.
[Issues I Will Consider Textbox]
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Issues I Will Consider
I will decide whether you continue to be disabled. To decide this issue, I will apply the
standard stated in sections 223(f) and 1614(a)(4) of the Social Security Act. I will consider:
•

Whether there has been any medical improvement relating to your ability to work
since we last found you disabled; and

•

Whether one of the exceptions to medical improvement stated in the Act and our
regulations applies.

In addition, if I decide that your disability ended, I will also determine whether you have
again become disabled since then.
Our regulations explain the rules for deciding whether you are still disabled and, if not, when
your disability ended. These rules are in the Code of Federal Regulations, Title 20, Chapter
III, Part 404, Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]
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Issues I Will Consider
I will decide whether you continue to be disabled. To decide this issue, I will apply the
standard stated in sections 223(f) and 1614(a)(4) of the Social Security Act. I will consider:
•

Whether there has been any medical improvement relating to your ability to work
since we last found you disabled; and

•

Whether one of the exceptions to medical improvement stated in the Act and our
regulations applies.

In addition, if I decide that your disability ended, I will also determine whether you have
again become disabled since then.

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ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

Our regulations explain the rules for deciding whether you are still disabled and, if not, when
your disability ended. These rules are in the Code of Federal Regulations, Title 20, Chapter
III, Part 404, Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]
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Issues I Will Consider
I will decide whether you continue to be disabled. To decide this issue, I will apply the
standards stated in sections 1614(a) (3)(C), (a)(4)(B), and (c) of the Social Security Act. I will
consider:
•

Whether there has been any medical improvement in the impairment(s) that was
present at the time of your most recent favorable determination or decision; and

•

Whether your impairment(s) still meets, medically equals, or functionally equals the
requirements of a listed impairment in Appendix 1 of Subpart P of our regulations;
and

•

Whether you are currently disabled, considering all current impairments.

In addition, I will also determine whether an exception to medical improvement applies.
The child should be present at this hearing so I can consider the
case fully.
[Issues I Will Consider Textbox]
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Issues I Will Consider
I will decide whether you continue to be disabled. To decide this issue, I will determine
whether you are disabled under section 1614(a)(3)(A) of the Social Security Act (the Act).
Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

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[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]
•

Page X of X

Has lasted 12 continuous months, can be expected to last 12 continuous months, or
can be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work, if any, you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and work
experience.

Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 416, Subpart I.
[Issues I Will Consider Textbox]
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Issues I Will Consider
The general issue is whether you were overpaid benefits within the meaning of section 204 of
the Social Security Act.
[Issues I Will Consider Textbox]
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Issues I Will Consider
The specific issues are whether you were “without fault” as defined in 20 CFR § 404.507 in
causing the overpayment and, if so, whether recovery of the overpayment would (1) defeat the
purpose of Title II of the Social Security Act, as defined in 20 CFR § 404.508, or (2) be
against equity and good conscience as defined in 20 CFR § 404.509.
[Issues I Will Consider Textbox]
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Issues I Will Consider
The general issues are whether you were overpaid benefits within the meaning of section 204
of the Social Security Act (Act) and, if so, whether recovery of the overpayment may be
waived.
The specific issues are whether you were “without fault” as defined in 20 CFR § 404.507 in
causing the overpayment and, if so, whether recovery of the overpayment would (1) defeat the
purpose of Title II of the Act, as defined in 20 CFR § 404.508, or (2) be against equity and
good conscience as defined in 20 CFR § 404.509.
[Issues I Will Consider Textbox]
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Issues I Will Consider
The general issue is whether you were overpaid benefits within the meaning of section 1631
of the Social Security Act.
[Issues I Will Consider Textbox]
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Issues I Will Consider
The specific issues are whether you were “without fault” as defined in 20 CFR § 416.552 in
causing the overpayment and, if so, whether recovery of the overpayment would (1) defeat the
purpose of Title XVI of the Social Security Act, as defined in 20 CFR § 416.553, (2) be
against equity and good conscience as defined in 20 CFR § 416.554, or (3) impede efficient or
effective administration of Title XVI due to the small amount involved as defined in 20 CFR
§ 416.555.
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Issues I Will Consider
The general issues are whether you were overpaid benefits within the meaning of section
1631 of the Social Security Act (Act) and, if so, whether recovery of the overpayment may be
waived.
The specific issues are whether you were “without fault” as defined in 20 CFR § 416.552 in
causing the overpayment and, if so, whether recovery of the overpayment would (1) defeat the
purpose of Title XVI of the Act, as defined in 20 CFR § 416.553, (2) be against equity and
good conscience as defined in 20 CFR § 416.554, or (3) impede efficient or effective
administration of Title XVI due to the small amount involved as defined in 20 CFR §
416.555.
[Issues I Will Consider Textbox]
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Issues I Will Consider
The general issue is whether you were overpaid benefits within the meaning of sections 204
and 1631 of the Social Security Act.
[Issues I Will Consider Textbox]
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Issues I Will Consider
The specific issues are whether you were “without fault” as defined in 20 CFR § 404.507 and
416.552 in causing the overpayment and, if so, whether recovery of the overpayment would
(1) defeat the purpose of Title II and Title XVI of the Social Security Act, as defined in 20
CFR § 404.508 and 416.553, (2) be against equity and good conscience as defined in 20 CFR
§ 404.509 and 416.554, or (3) impede efficient or effective administration of Title XVI due to
the small amount involved as defined in 20 CFR § 416.555.
[Issues I Will Consider Textbox]
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[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

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Issues I Will Consider
The general issues are whether you were overpaid benefits within the meaning of sections 204
and 1631 of the Social Security Act (Act) and, if so, whether recovery of the overpayment
may be waived.
The specific issues are whether you were “without fault” as defined in 20 CFR § 404.507 and
416.552 in causing the overpayment and, if so, whether recovery of the overpayment would
(1) defeat the purpose of Title II and Title XVI of the Act, as defined in 20 CFR § 404.508
and 416.553, (2) be against equity and good conscience as defined in 20 CFR § 404.509 and
416.554, or (3) impede efficient or effective administration of Title XVI due to the small
amount involved as defined in 20 CFR § 416.555.
[Issues I Will Consider Textbox]

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Issues I Will Consider
The general issue is whether you are entitled to child's insurance benefits within the meaning
of section 202(d) of the Social Security Act.
The specific issues are whether you are dependent on the insured individual or were
dependent on the insured individual at the time of their death; you are unmarried; and whether
the insured individual is fully insured or was fully insured at the time of their death.
[Issues I Will Consider Textbox]

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Issues I Will Consider

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[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

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The general issue is whether you are entitled to widow(er)'s benefits under section 202(f) of
the Social Security Act.
The specific issues are whether you are the widow(er)'s based on a relationship described
under 20 CFR §§ 404.345, 404.346 of a person who was fully insured when they died;
whether the conditions under 20 CFR § 404.335 are met; whether you are at least 60 years
old; and whether you are unmarried.
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Issues I Will Consider
The general issue is whether you arewere entitled to wife’s insurance benefits under section 202(b) of
the Social Security Act.
The specific issue is whether you arewere the legal wife of a fully insured wage earner. This will
be determined by whether your relationship iswas one described in 20 CFR §§ 404.345
or 404.346, and whether one of the conditions set forth under 20 CFR § 404.330 is met.
[Issues I Will Consider Textbox]
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Issues I Will Consider
The general issue is whether you arewere entitled to
divorced wife’s insurance benefits under section 202(b) of the Social Security Act.
The specific issue is whether you arewere the legal
divorced wife of a fully insured wage earner. This will be determined by whether your
relationship iswas one described in 20 CFR §§
404.345or 404.346, and whether one of the conditions set forth under 20 CFR § 404.330 is
met.
[Issues I Will Consider Textbox]

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Issues I Will Consider
The general issue is whether you arewere entitled to husband’s insurance benefits under
section 202(c) of the Social Security Act.
The specific issue is whether you arewere the legal husband of a fully insured wage earner.
This will be determined by whether your relationship iswas one described in 20 CFR §§
404.345, 404.346, and whether one of the conditions set forth under 20 CFR § 404.330 is met.
[Issues I Will Consider Textbox]
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Issues I Will Consider
The general issue is whether you arewere entitled to
divorced husband’s insurance benefits under section 202(c) of the Social Security Act.
The specific issue is whether you arewere the legal
divorced husband of a fully insured wage earner. This will be determined by whether your
relationship iswas one described in 20 CFR §§ 404.345
or 404.346, and whether one of the conditions set forth under 20 CFR § 404.330 is met.
[Issues I Will Consider Textbox]

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Issues I Will Consider
The general issue is whether you are eligible for supplemental security income under sections
1602 and 1611 of the Social Security Act. The specific issue is whether you have income or
resources in excess of the amount set by the regulations as the maximum allowable to be
eligible for supplemental security income.
[Issues I Will Consider Textbox]
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Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for Disabled Widow(er)’s
Insurance Benefits based upon disability under section 202(e)(f) of the Social Security Act (Act). The hearing also concerns your
application of [Title XVI AppDate], for Supplemental Security Income (SSI). I will consider
whether you are disabled under section 216(i), section 223(d), and section 1614(a)(3) of the
Act.
To decide whether you are entitled to widow(er)’s benefits, as described in 20 C.F.R.
404.335, I will consider whether:
• The decedent had enough earnings under Social Security to be fully insured;
• You qualify as the decedent’s surviving divorced
spousewidow(er);
• You are age 50 or older;
• You have a disability as defined in the Act; and
• Your disability began on or before [DatePrescribedPeriodEnds], the end of a special
period set by law.
This period begins with the later of:
• The month of the worker’s death; or
• The last month you were entitled to a survivor’s benefit on the worker’s record.
This period ends with the earlier of:
• The month before you turn age 60; or
• 7 years after the period began.
Under the Act, I will find you disabled for those benefits or SSI if you have a physical or
mental condition(s) that:

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•

Keeps you from doing any substantial gainful work; and

•

Has lasted or is expected to last for a continuous period of at least 12 months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step during which I can make a decision. The steps in this process look at:
•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and work
experience.

Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B and Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]
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Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for Disabled Widow(er)’s
Insurance, Period of Disability, and Disability Insurance Benefits under sections 202(e)(f), 216(i) and 223(a) of the Social Security Act (Act). I will
consider whether you are disabled under sections 216(i) and 223(d) of the Act.
To decide whether you are entitled to widow(er)’s benefits as described in 20 C.F.R. 404.335,
I will consider whether:
•

The decedent had enough earnings under Social Security to be fully insured;

•

You qualify as the decedent’s surviving divorced
spousewidow(er);

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•

You are age 50 or older;

•

You have a disability as defined in the Act; and

•

Your disability began on or before [DatePrescribedPeriodEnds], the end of a special
period set by law.

This period begins with the later of:
•

The month of the worker’s death; or

•

The last month you were entitled to a survivor’s benefit on the worker’s record.

This period ends with the earlier of:
•

The month before you turn age 60; or

•

7 years after the period began.

Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted or is expected to last for a continuous period of at least 12 months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and work
experience.

I will also consider whether you have enough earnings under Social Security to be insured for
a Period of Disability and Disability Insurance Benefits. If you do, I must decide whether you
became disabled while you were insured.
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ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

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Our records indicate that your date last insured is [DLI Date]. If this is
correct, I must decide whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B and Subpart P.
[Issues I Will Consider Textbox]
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Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for Disabled Widow(er)’s
Insurance, a Period of Disability, and Disability Insurance Benefits under sections 202(e)(f), 216(i) and 223(a) of the Social Security Act (Act). The
hearing also concerns your application of [Title XVI AppDate], for Supplemental Security
Income (SSI). I will consider whether you are disabled under section 216(i), section 223(d),
and section 1614(a)(3) of the Act.
To decide whether you are entitled to widow(er)’s benefits, as described in 20 C.F.R.
404.335, I will consider whether:
•

The decedent had enough earnings under Social Security to be fully insured;

•

You qualify as the decedent’s surviving divorced
spousewidow(er);

•

You are age 50 or older;

•

You have a disability as defined in the Act; and

•

Your disability began on or before [DatePrescribedPeriodEnds], the end of a special
period set by law.

This period begins with the later of:
•

The month of the worker’s death; or

•

The last month you were entitled to a survivor’s benefit on the worker’s record.

This period ends with the earlier of:
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]
•

The month before you turn age 60; or

•

7 years after the period began.

Page X of X

Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted or is expected to last for a continuous period of at least 12 months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step during which I can make a decision. The steps in this process look at:
•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and work
experience.

I will also consider whether you have enough earnings under Social Security to be insured for
a Period of Disability and Disability Insurance Benefits. If you do, I must decide whether you
became disabled while you were insured.
Our records indicate that your date last insured is [DLI Date]. If this is
correct, I must decide whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B and Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]
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Issues I Will Consider

Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

The general issue is whether you are entitled to child's insurance benefits within the meaning
of section 202(d) of the Social Security Act.
The specific issues are whether you are dependent on the insured individual or were
dependent on the insured individual at the time of their death; you are unmarried; and whether
the insured individual is fully insured or was fully insured at the time of their death.
[Issues I Will Consider Textbox]
Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for child’s benefits under
sections 202(d), 216(i), and 223(a) of the Social Security Act (Act). The hearing also concerns
your application of [Title XVI AppDate], for Supplemental Security Income (SSI). I will
consider whether you are disabled under section 216(i), section 223(d), and section 1614(a)(3)
of the Act.
To decide whether you are entitled to child’s benefits, as described in 20 CFR 404.350, I will
consider whether you:
•

Are the insured person’s child, based upon a relationship described in 20 CFR 404.355
through 404.359;

•

Are dependent on the insured, as defined in 20 CFR 404.360 through 404.365;

•

Filed an application;

•

Are unmarried; and

•

Are under age 18; or are 18 years old or older and have a disability that began before
22 years old; or are 18 years or older and qualify for benefits as a full-time student as
described in 20 CFR 404.367.

Under the Act, I will find you disabled for those benefits or SSI if you have a physical or
mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted or is expected to last for a continuous period of at least 12 months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step during which I can make a decision. The steps in this process look at:
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and work
experience.

Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B, Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]
Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for child’s benefits under
sections 202(d), 216(i), and 223(a) of the Social Security Act (Act). The hearing also concerns
your application of [Title XVI AppDate], for Supplemental Security Income (SSI). I will
consider whether you are disabled under section 216(i), section 223(d), and section 1614(a)(3)
of the Act.
To decide whether you are entitled to child’s benefits, as described in 20 CFR 404.350, I will
consider whether you:
•

Are the insured person’s child, based upon a relationship described in 20 CFR 404.355
through 404.359;

•

Are dependent on the insured, as defined in 20 CFR 404.360 through 404.365;

•

Filed an application;

•

Are unmarried; and

•

Are under age 18; or are 18 years old or older and have a disability that began before
22 years old; or are 18 years or older and qualify for benefits as a full-time student as
described in 20 CFR 404.367.
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

Under the Act, I will find you disabled for those benefits or SSI if you have a physical or
mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted or is expected to last for a continuous period of at least 12 months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step during which I can make a decision. The steps in this process look at:
•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and work
experience.

Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B, Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]
Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for child’s benefits, a Period of
Disability, and Disability Insurance Benefits under sections 202(d), 216(i), and 223(a) of the
Social Security Act (Act). I will consider whether you are disabled under sections 216(i) and
223(d) of the Act.
To decide whether you are entitled to child’s benefits, as described in 20 CFR 404.350, I will
consider whether you:
•

Are the insured person’s child, based upon a relationship described in 20 CFR 404.355
through 404.359;
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

•

Are dependent on the insured, as defined in 20 CFR 404.360 through 404.365;

•

Filed an application;

•

Are unmarried; and

•

Are under age 18; or are 18 years old or older and have a disability that began before
22 years old; or are 18 years or older and qualify for benefits as a full-time student as
described in 20 CFR 404.367.

Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted or is expected to last for a continuous period of at least 12 months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step during which I can make a decision. The steps in this process look at:
•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and work
experience.

I will also consider whether you have enough earnings under Social Security to be insured for
a Period of Disability and Disability Insurance Benefits. If you do, I must decide whether you
became disabled while you were insured.
Our records indicate that your date last insured is [DLI Date]. If this is
correct, I must decide whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B and Subpart P.
[Issues I Will Consider Textbox]
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for child’s benefits, a Period of
Disability, and Disability Insurance Benefits under sections 202(d), 216(i), and 223(a) of the
Social Security Act (Act). I will consider whether you are disabled under sections 216(i) and
223(d) of the Act.
To decide whether you are entitled to child’s benefits, as described in 20 CFR 404.350, I will
consider whether you:
•

Are the insured person’s child, based upon a relationship described in 20 CFR 404.355
through 404.359;

•

Are dependent on the insured, as defined in 20 CFR 404.360 through 404.365;

•

Filed an application;

•

Are unmarried; and

•

Are under age 18; or are 18 years old or older and have a disability that began before
22 years old; or are 18 years or older and qualify for benefits as a full-time student as
described in 20 CFR 404.367.

Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted or is expected to last for a continuous period of at least 12 months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step during which I can make a decision. The steps in this process look at:
•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]
•

Page X of X

Whether you can do any other kind of work considering your age, education, and work
experience.

I will also consider whether you have enough earnings under Social Security to be insured for
a Period of Disability and Disability Insurance Benefits. If you do, I must decide whether you
became disabled while you were insured.
Our records indicate that your date last insured is [DLI Date]. If this is
correct, I must decide whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B and Subpart P.
[Issues I Will Consider Textbox]
Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for child’s benefits, a Period of
Disability, and Disability Insurance Benefits under sections 202(d), 216(i), and 223(a) of the
Social Security Act (Act). The hearing also concerns your application of [Title XVI
AppDate], for Supplemental Security Income (SSI). I will consider whether you are disabled
under section 216(i), section 223(d), and section 1614(a)(3) of the Act.
To decide whether you are entitled to child’s benefits, as described in 20 CFR 404.350, I will
consider whether you:
•

Are the insured person’s child, based upon a relationship described in 20 CFR 404.355
through 404.359;

•

Are dependent on the insured, as defined in 20 CFR 404.360 through 404.365;

•

Filed an application;

•

Are unmarried; and

•

Are under age 18; or are 18 years old or older and have a disability that began before
22 years old; or are 18 years or older and qualify for benefits as a full-time student as
described in 20 CFR 404.367.

Under the Act, I will find you disabled for those benefits or SSI if you have a physical or
mental condition(s) that:
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

•

Keeps you from doing any substantial gainful work; and

•

Has lasted or is expected to last for a continuous period of at least 12 months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step during which I can make a decision. The steps in this process look at:
•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and work
experience.

I will also consider whether you have enough earnings under Social Security to be insured for
a Period of Disability and Disability Insurance Benefits. If you do, I must decide whether you
became disabled while you were insured.
Our records indicate that your date last insured is [DLI Date]. If this is
correct, I must decide whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B, Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]

Return to More About the Issues

Issues I Will Consider
[Issues I Will Consider Textbox]

Return to More About the Issues

Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for Medicare benefits under Part
A of Title XVIII of the Social Security Act (the Act) as a Medicare for Qualified Government
Employment (MQGE) claim. I will consider whether you are disabled under sections 223(d)
and 226(b) of the Act.
Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted 12 continuous months, can be expected to last for 12 continuous months, or
can be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and work
experience.

I will also consider whether you have enough earnings under Social Security to be insured for
Medicare benefits only. If you do, I must decide whether you became disabled while you were
insured.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B and Subpart P.
[Issues I Will Consider Textbox]

Return to More About the Issues

Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for Disabled Widow(er)’s
Insurance Benefits under section 202(e) or (f) of the Social Security Act (Act). The hearing
also concerns your application of [Title XVIII AppDate], for Medicare benefits under Part A
of Title XVIII of the Act, as a Medicare for Qualified Government Employment (MQGE)
claim. I will consider whether you are disabled under sections 223(d) and 226(b) of the Act.
To decide your case, I will consider whether:
• The deceased had enough earnings under Social Security to be fully insured;
• You qualify as the decedent's widow(er);
• You are age 50 or older;
• You have a disability as defined in the Act; and
• Your disability began on or before [DatePrescribedPeriodEnds], the end of a special
period set by law.
This period begins with the later of:
• The month of the worker’s death; or
• The last month you were entitled to a survivor’s benefit on the worker’s record.
This period ends with the earlier of:
• The month before you turn age 60; or
• 7 years after the period began.
Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted 12 continuous months, can be expected to last for 12 continuous months,
or can be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and
work experience.

I will also consider whether you have enough earnings to be insured for MQGE or Medicare
Part A (Hospital Insurance) benefits. If you do, I must decide whether you became disabled
while you were insured.
Our records indicate that your date last insured for purposes of your
MQGE claim is [DLI Date] for Medicare Part A benefits. If this is correct, I must decide
whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B, Subpart D, and Subpart P.
[Issues I Will Consider Textbox]

Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for Disabled Widow(er)’s
Insurance Benefits, under section 202 (e) or (f) of the Social Security Act (Act) and your
[Title XVIII AppDate] application for Medicare benefits, under Part A of Title XVIII of the
Act, as a Medicare for Qualified Government Employment (MQGE) claim. The hearing also
concerns your application of [Title XVI AppDate], for Supplemental Security Income (SSI). I
will consider whether you are disabled under sections 223(d), 226(b), and 1614(a)(3) of the
Act.
To decide your case, I will consider whether:

Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

• The deceased had enough earnings under Social Security to be fully insured;
• You qualify as the decedent's widow(er);
• You are age 50 or older;
• You have a disability as defined in the Act; and
• Your disability began on or before [DatePrescribedPeriodEnds], the end of a special
period set by law.
This period begins with the later of:
• The month of the worker’s death; or
• The last month you were entitled to a survivor’s benefit on the worker’s record.
This period ends with the earlier of:
• The month before you turn age 60; or
• 7 years after the period began.
Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted 12 continuous months, can be expected to last for 12 continuous months,
or can be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
•

Any work you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and
work experience.

Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

Our records indicate that your date last insured for purposes of your
MQGE claim is [DLI Date]. If this is correct, I must decide whether you became disabled on
or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B, Subpart D, and Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]

Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for Child’s Insurance Benefits
under section 202(d) of the Social Security Act (Act). The hearing also concerns your
application of [Title XVIII AppDate], for Medicare benefits under Part A of Title XVIII of
the Act as a Medicare for Qualified Government Employment (MQGE) claim. I will consider
whether you are disabled under sections 216(i), 223(d), and 226(b) of the Act.
To decide whether you are entitled to child’s benefits, as described in 20 CFR 404.350, I will
consider whether you:
•

Are the insured person’s child, based upon a relationship described in 20 CFR
404.355 through 404.359;

•

Are dependent on the insured, as defined in 20 CFR 404.360 through 404.365;

•

Filed an application;

•

Are unmarried; and

•

Are under age 18; or are 18 years old or older and have a disability that began before
22 years old; or are 18 years or older and qualify for benefits as a full-time student as
described in 20 CFR 404.367.

Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•
•

Keeps you from doing any substantial gainful work; and
Has lasted 12 straight months, can be expected to last for 12 straight months, or can
be expected to result in death.

Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
•

Any work that you have done after your condition(s) began;

•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and
work experience.

I will also consider whether you have enough earnings to be insured for Medicare Part A
benefits only. If you do, I must decide whether you became disabled while you were insured.
Our records indicate that your date last insured for purposes of your
MQGE claim is [DLI Date] for Medicare Part A benefits. If this date is correct, I must decide
whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B, Subpart P.
[Issues I Will Consider Textbox]

Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for a Period of Disability and
Disability Insurance Benefits under sections 216(i) and 223(a) of the Social Security Act
(Act). The hearing also concerns your application of [Title XVIII AppDate], for Medicare
benefits under Part A of Title XVIII of the Act as a Medicare for Qualified Government
Employment (MQGE) claim. I will consider whether you are disabled under sections 216(i),
223(d) and 226(b) of the Act.
Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
• Keeps you from doing any substantial gainful work; and

Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]
•

Page X of X

Has lasted 12 straight months, can be expected to last for 12 straight months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
• Any work that you have done after your condition(s) began;
•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and
work experience.

I will also consider whether you have enough earnings under Social Security to be insured for
a Period of Disability and Disability Insurance Benefits. If you do, I must decide whether you
became disabled while you were insured.
Our records indicate that your date last insured is [DLI Date]. If this
date is correct, I must decide whether you became disabled on or before that date.
I will also consider whether you have enough earnings to be insured for Medicare Part A
benefits only. If you do, I must decide whether you became disabled while you were insured.
Our records indicate that your date last insured for purposes of your
MQGE claim is [DLI Date] for Medicare Part A benefits. If this date is correct, I must decide
whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B and Subpart P.
[Issues I Will Consider Textbox]

Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title II DWB AppDate], for Disabled Widow(er)’s
Insurance Benefits under sections 202(e) or (f) of the Social Security Act (Act), and your
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

application of [Title II DIB AppDate], for a Period of Disability and Disability Insurance
Benefits under 216(i) and 223(a) of the Act. The hearing also concerns your application of
[Title XVIII AppDate], for Medicare benefits under Part A of Title XVIII of the Act as a
Medicare for Qualified Government Employment (MQGE) claim. I will consider whether you
are disabled under sections 216(i), 223(d) and 226(b) of the Act.
To decide whether you are eligible for Disabled Widow(er)’s Benefits, I will consider
whether:
• The decedent had enough earnings under Social Security to be fully insured;
•

You qualify as the decedent’s surviving divorced spousesurviving spouse;

•

You are age 50 or older;

•

You have a disability as defined in the Act; and

•

Your disability began on or before [DatePrescribedPeriodEnds], the end of a special
period set by law.

This period begins with the later of:
•

The month of the worker’s death; or

•

The last month you were entitled to a survivor’s benefit on the worker’s record.

This period ends with the earlier of:
•

The month before you turn age 60; or

•

7 years after the period began.

Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•

Keeps you from doing any substantial gainful work; and

•

Has lasted 12 straight months, can be expected to last for 12 straight months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
•

Any work that you have done after your condition(s) began;

•

The severity of your condition(s);
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and
work experience.

I will also consider whether you have enough earnings under Social Security to be insured for
a Period of Disability and Disability Insurance Benefits. If you do, I must decide whether you
became disabled while you were insured.
Our records indicate that your date last insured is [DLI Date]. If this
date is correct, I must decide whether you became disabled on or before that date.
I will also consider whether you have enough earnings to be insured for Medicare Part A
benefits only. If you do, I must decide whether you became disabled while you were insured.
Our records indicate that your date last insured for purposes of your
MQGE claim is [DLI Date] for Medicare Part A benefits. If this date is correct, I must decide
whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B and Subpart P.
[Issues I Will Consider Textbox]

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Issues I Will Consider
The hearing concerns your application of [Title II CDB AppDate], for Child’s Insurance
Benefits under section 202(d) of the Social Security Act (Act), and your application of [Title
II DIB AppDate], for a Period of Disability and Disability Insurance Benefits under sections
216(i) and 223(a) of the Act. The hearing also concerns your application of [Title XVIII
AppDate], for Medicare benefits under Part A of Title XVIII of the Act as a Medicare for
Qualified Government Employment (MQGE) claim. I will consider whether you are disabled
under sections 216(i), 223(d), and 226(b) of the Act.

Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

To decide whether you are entitled to child’s benefits, as described in 20 CFR 404.350, I will
consider whether you:
• Are the insured person’s child, based upon a relationship described in 20 CFR
404.355 through 404.359;
•

Are dependent on the insured, as defined in 20 CFR 404.360 through 404.365;

•

Filed an application;

•

Are unmarried; and

•

Are under age 18; or are 18 years old or older and have a disability that began before
22 years old; or are 18 years or older and qualify for benefits as a full-time student as
described in 20 CFR 404.367.

Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•
•

Keeps you from doing any substantial gainful work; and
Has lasted 12 straight months, can be expected to last for 12 straight months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
• Any work that you have done after your condition(s) began;
•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and
work experience.

I will also consider whether you have enough earnings under Social Security to be insured for
a Period of Disability and Disability Insurance Benefits. If you do, I must decide whether you
became disabled while you were insured.
Our records indicate that your date last insured is [DLI Date]. If this
date is correct, I must decide whether you became disabled on or before that date.
I will also consider whether you have enough earnings to be insured for Medicare Part A
benefits only. If you do, I must decide whether you became disabled while you were insured.

Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

Our records indicate that your date last insured for purposes of your
MQGE claim is [DLI Date] for Medicare Part A benefits. If this date is correct, I must decide
whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B, Subpart P.
[Issues I Will Consider Textbox]

Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for a Period of Disability and
Disability Insurance Benefits under sections 216(i) and 223(a) of the Social Security Act
(Act). The hearing also concerns your application of [Title XVI AppDate], for Supplemental
Security Income (SSI) under section 1614(a)(3) of the Act. The hearing also concerns your
application of [Title XVIII AppDate], for Medicare benefits under Part A of Title XVIII of
the Act as a Medicare for Qualified Government Employment (MQGE) claim. I will consider
whether you are disabled under sections 216(i), 223(d), 226(b), and 1614(a)(3) of the Act.
Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
• Keeps you from doing any substantial gainful work; and
•

Has lasted 12 straight months, can be expected to last for 12 straight months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
• Any work that you have done after your condition(s) began;
•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and
work experience.

Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

I will also consider whether you have enough earnings under Social Security to be insured for
a Period of Disability and Disability Insurance Benefits. If you do, I must decide whether you
became disabled while you were insured.
Our records indicate that your date last insured is [DLI Date]. If this
date is correct, I must decide whether you became disabled on or before that date.
I will also consider whether you have enough earnings to be insured for Medicare Part A
benefits only. If you do, I must decide whether you became disabled while you were insured.
Our records indicate that your date last insured for purposes of your
MQGE claim is [DLI Date] for Medicare Part A benefits. If this date is correct, I must decide
whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B, Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]

Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title II DWB AppDate], for Disabled Widow(er)’s
Insurance Benefits under sections 202(e) or (f) of the Social Security Act (Act), and your
application of [Title II DIB AppDate], for a Period of Disability and Disability Insurance
Benefits under sections 216(i) and 223(a) of the Act. The hearing also concerns your
application of [Title XVI AppDate], for Supplemental Security Income (SSI) under section
1614(a)(3) of the Act. The hearing also concerns your application of [Title XVIII AppDate],
for Medicare benefits under Part A of Title XVIII of the Act as a Medicare for Qualified
Government Employment (MQGE) claim. I will consider whether you are disabled under
sections 216(i), 223(d), 226(b), and 1614(a)(3) of the Act.
To decide whether you are eligible for Disabled Widow(er)’s Benefits, I will consider
whether:
• The decedent had enough earnings under Social Security to be fully insured;
•

You qualify as the decedent’s surviving divorced spousesurviving spouse;
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

•

You are age 50 or older;

•

You have a disability as defined in the Act; and

•

Your disability began on or before [DatePrescribedPeriodEnds], the end of a special
period set by law.

This period begins with the later of:
•
•

The month of the worker’s death; or
The last month you were entitled to a survivor’s benefit on the worker’s record.

This period ends with the earlier of:
•
•

The month before you turn age 60; or
7 years after the period began.

Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•
•

Keeps you from doing any substantial gainful work; and
Has lasted 12 straight months, can be expected to last for 12 straight months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
• Any work that you have done after your condition(s) began;
•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and
work experience.

I will also consider whether you have enough earnings under Social Security to be insured for
a Period of Disability and Disability Insurance Benefits. If you do, I must decide whether you
became disabled while you were insured.
Our records indicate that your date last insured is [DLI Date]. If this
date is correct, I must decide whether you became disabled on or before that date.

Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

I will also consider whether you have enough earnings to be insured for Medicare Part A
benefits only. If you do, I must decide whether you became disabled while you were insured.
Our records indicate that your date last insured for purposes of your
MQGE claim is [DLI Date] for Medicare Part A benefits. If this date is correct, I must decide
whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B and Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]

Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title XVIII AppDate], for Medicare benefits under
Part A of Title XVIII of the Social Security Act (Act) as a Medicare for Qualified
Government Employment (MQGE) claim. The hearing also concerns your application of
[Title XVI AppDate], for Supplemental Security Income (SSI) under section 1614(a)(3) of the
Act. I will consider whether you are disabled under sections 223(d), 226(b), and 1614(a)(3) of
the Act.
Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•
•

Keeps you from doing any substantial gainful work; and
Has lasted 12 straight months, can be expected to last for 12 straight months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
• Any work that you have done after your condition(s) began;
•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]
•

Page X of X

Whether you can do any other kind of work considering your age, education, and
work experience.

I will also consider whether you have enough earnings to be insured for Medicare Part A
benefits only. If you do, I must decide whether you became disabled while you were insured.
Our records indicate that your date last insured for purposes of your
MQGE claim is [DLI Date] for Medicare Part A benefits. If this date is correct, I must decide
whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B, Subpart P, and Part 416, Subpart I.
[Issues I Will Consider Textbox]

Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title II AppDate], for Child’s Insurance Benefits
under section 202(d) of the Social Security Act (Act). The hearing also concerns your
application of [Title XVI AppDate], for Supplemental Security Income (SSI) under section
1614(a)(3) of the Act. The hearing also concerns your application of [Title XVIII AppDate],
for Medicare benefits under Part A of Title XVIII of the Act as a Medicare for Qualified
Government Employment (MQGE) claim. I will consider whether you are disabled under
sections 216(i), 223(d), 226(b), and 1614(a)(3) of the Act.
To decide whether you are entitled to child’s benefits, as described in 20 CFR 404.350, I will
consider whether you:
• Are the insured person’s child, based upon a relationship described in 20 CFR
404.355 through 404.359;
•

Are dependent on the insured, as defined in 20 CFR 404.360 through 404.365;

•

Filed an application;

•

Are unmarried; and

•

Are under age 18; or are 18 years old or older and have a disability that began before
22 years old; or are 18 years or older and qualify for benefits as a full-time student as
described in 20 CFR 404.367.
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•
•

Keeps you from doing any substantial gainful work; and
Has lasted 12 straight months, can be expected to last for 12 straight months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
• Any work that you have done after your condition(s) began;
•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and
work experience.

I will also consider whether you have enough earnings to be insured for Medicare Part A
benefits only. If you do, I must decide whether you became disabled while you were insured.
Our records indicate that your date last insured for purposes of your
MQGE claim is [DLI Date] for Medicare Part A benefits. If this date is correct, I must decide
whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B, Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]

Return to More About the Issues

Issues I Will Consider
The hearing concerns your application of [Title II CDB AppDate], for Child’s Insurance
Benefits under section 202(d) of the Social Security Act (Act) and your application of [Title II
DIB AppDate], for a Period of Disability and Disability Insurance Benefits under sections
216(i) and 223(a) of the Act. The hearing also concerns your application of [Title XVI
AppDate], for Supplemental Security Income (SSI) under section 1614(a)(3) of the Act. The
hearing also concerns your application of [Title XVIII AppDate], for Medicare benefits under
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

Part A of Title XVIII of the Act as a Medicare for Qualified Government Employment
(MQGE) claim. I will consider whether you are disabled under sections 216(i), 223(d),
226(b), and 1614(a)(3) of the Act.
To decide whether you are entitled to child’s benefits, as described in 20 CFR 404.350, I will
consider whether you:
• Are the insured person’s child, based upon a relationship described in 20 CFR
404.355 through 404.359;
•

Are dependent on the insured, as defined in 20 CFR 404.360 through 404.365;

•

Filed an application;

•

Are unmarried; and

•

Are under age 18; or are 18 years old or older and have a disability that began before
22 years old; or are 18 years or older and qualify for benefits as a full-time student as
described in 20 CFR 404.367.

Under the Act, I will find you disabled if you have a physical or mental condition(s) that:
•
•

Keeps you from doing any substantial gainful work; and
Has lasted 12 straight months, can be expected to last for 12 straight months, or can
be expected to result in death.

I will follow a step-by-step process to decide whether you are disabled. I will stop the process
at the first step I can make a decision. The steps in this process look at:
• Any work that you have done after your condition(s) began;
•

The severity of your condition(s);

•

Whether your condition(s) meets or medically equals one of the impairments
described in the Social Security regulations known as the “Listing of Impairments”;

•

Whether you can do the kind of work you did in the past; and

•

Whether you can do any other kind of work considering your age, education, and
work experience.

I will also consider whether you have enough earnings under Social Security to be insured for
a Period of Disability and Disability Insurance Benefits. If you do, I must decide whether you
became disabled while you were insured.
Our records indicate that your date last insured is [DLI Date]. If this
date is correct, I must decide whether you became disabled on or before that date.
Form HA-83 (01-2022)
ClaimantRepresentative

[ClaimantFullName] BNC#: [BeneficiaryNoticeControl]

Page X of X

I will also consider whether you have enough earnings to be insured for Medicare Part A
benefits only. If you do, I must decide whether you became disabled while you were insured.
Our records indicate that your date last insured for purposes of your
MQGE claim is [DLI Date] for Medicare Part A benefits. If this date is correct, I must decide
whether you became disabled on or before that date.
Our regulations explain the rules for deciding whether you are disabled and, if so, when you
became disabled. These rules are in the Code of Federal Regulations, Title 20, Chapter III,
Part 404, Subpart B, Subpart P and Part 416, Subpart I.
[Issues I Will Consider Textbox]

Return to More About the Issues

Form HA-83 (01-2022)
ClaimantRepresentative