[Code of Federal Regulations]
[Title 20, Volume 2]
[Revised as of April 1, 2004]
From the U.S. Government Printing Office via GPO Access
[CITE: 20CFR422.515]

[Page 1093]
 
                      TITLE 20--EMPLOYEES' BENEFITS
 
               CHAPTER III--SOCIAL SECURITY ADMINISTRATION
 
PART 422_ORGANIZATION AND PROCEDURES--Table of Contents
 
                Subpart F_Applications and Related Forms
 
Sec. 422.515  Forms used for withdrawal, reconsideration and other appeals, 
and appointment of representative.

    The following is a list of forms prescribed by the Social Security 
Administration for use by the public to request a withdrawal of an 
application, a reconsideration of an initial determination, a hearing, a 
review of an administrative law judge's decision, or for use where a 
person is authorized to represent a claimant.

SSA-521--Request for Withdrawal of Application. (For use by an 
individual to cancel his application.)
SSA-561--Request for Reconsideration. (For use by an individual who 
disagrees with an initial determination concerning (a) entitlement to 
benefits or any other right under title II of the Social Security Act, 
or (b) entitlement to hospital insurance benefits or supplementary 
medical insurance benefits under title XVIII of the act, or (c) 
entitlement to black lung benefits under title IV of the Federal Coal 
Mine Health and Safety Act. See Sec. 422.140 for a discussion of the 
reconsideration procedure.)
SSA-1696--Appointment of Representative. (For use by person other than 
an attorney authorized by a claimant to act for him in a claim or 
related matter.)
SSA-1763--Request for Termination of Supplementary Medical Insurance. 
(For use by an enrollee in requesting that his supplementary medical 
insurance coverage be terminated.)
SSA-1965--Request for Hearing--Part B Medicare Claim. (For use by an 
individual enrollee or his assignee to obtain a hearing before a hearing 
officer designated by the carrier concerning benefits payable under part 
B of title XVIII.)
HA-501--Request for Hearing. (For use by an individual or institution to 
obtain a hearing on a claim for title II benefits before an 
administrative law judge of the Social Security Administration.)

    Note: This form is also used to request a hearing regarding 
entitlement to hospital insurance benefits or supplementary medical 
insurance benefits under title XVIII of the act. (See Sec. 422.203 for 
a discussion of the hearing procedure.)

HA-501.1--Request for Hearing--Part A Health Insurance. (For use by an 
individual or institution to obtain a hearing before an administrative 
law judge of the Social Security Administration concerning the amount of 
hospital insurance benefits under title XVIII.)
HA-512.1--Notice by Attorney of Appointment as Representative. (For use 
by an attorney authorized by a claimant to act for him in a claim or 
related matter.)
HA-520--Request for Review of Hearing Examiner's Action. (For use by an 
individual or institution to obtain a review of a decision by an 
administrative law judge of the Social Security Administration.)

[38 FR 11452, May 8, 1973]