TN 26 (02-18)

A. Completing and distributing the Form HA-501-U5 (Request for Hearing by Administrative Law Judge) (HA-501-U5)

Use the HA-501-U5 to request a hearing for a determination or decision listed in GN 03101.010A.1.

1. Complete the HA-501-U5 as follows

• Enter information about the claimant in numbers 1 through 8.

• Complete number 3 if the claim number is different from the claimant’s social security number (SSN) and enter the claim number, SSN and beneficiary identification code, as it appears on the notice from the Social Security Administration.

• Do not complete number 6 for a Medicare issue.

• Numbers 9 through 16 collect information that the Office of Hearings Operations (OHO) needs to process the request for hearing. A field office (FO) technician completes numbers 9 through 16 of the HA-501. The receipt date for the request for hearing is the walk-in date, email date, fax date, or postmark date on the envelope.

2. Distribute the HA-501 as follows

The pre-printed form HA-501-U5 consists of five copies. An FO technician distributes all copies of the form to the appropriate folder, office and individuals as detailed in the below list of copies. Distribute the forms as listed, regardless of whether you use the preprinted, MCS, MSSICS, or pdf version of the form to document the request for hearing.

• Original (claim folder) – white copy,

• Hearing Office – pink copy,

• FO – yellow copy,

• Claimant – white copy,

• Appointed Representative – white copy.

B. Where to find the HA-501-U5

Claimants can access the HA-501-U5

• on SSA.gov’s Forms page,

• by request from the National 800 Number or any SSA FO, or

• on SSA.gov’s iAppeals Medical or iAppeals Non-Medical Applications.

Technicians can access the HA-501-U5 in

• SSA’s Intranet inForms Library,

• the Modernized Claims System (MCS), or

• the Modernized Supplemental Security Income Claim System (MSSICS).

C. Procedure for when to use the Spanish Language HA-501-U5-SP

When a Spanish-speaking claimant is unable to or has problems with speaking or reading English,

• have him or her complete the HA-501-U5 –SP, and

• translate and transcribe the information provided on the HA-501-U5-SP to the HA-501-U5 and staple the forms together.

The HA-501-U5-SP is available at the inForms Library or OS 15030.018.

D. References

• GN 03101.020 Good Cause for Extending the Time Limit to File an Appeal

• GN 03101.125 iAppeals – General and Title II Instructions

• GN 03101.127 iAppeals Non-Medical – General and Title II Instructions

• GN 03103.010 The Hearing Process

• MSOM MCS 010.002 Appeal Establishment

• MSOM 020.001 Movement of MCS Records - Overview

• OS 15030.017. HA-501-U5 (Request for Hearing by Administrative Law Judge)