Go to OS 15020.090 to obtain the most current Form.

A. General

The SSA-789-U4 is to be used in filing requests for reconsideration on continuing disability issues. Where a claimant is requesting reconsideration on a disability issue on more than one entitlement, complete only one SSA-789-U4. To request reconsideration with respect to nondisability issues, as well as (SGA), the SSA-561-U2, Request for Reconsideration should be used. It is essential to complete the SSA-789-U4 correctly because the DHU will rely on the information on this form in order to schedule hearings. The SSA-789 must be dated at the top of the form upon receipt in the FO.

B. Identifying Information

Provide the claimant's full name as shown on the cessation notice and the name of the number holder (NH), if different. Always enter the claimant's Social Security number (SSN) on line 1, regardless of whether it is the claim number on which the request for reconsideration is being filed. If the claimant's SSN is not the claim number, provide the NH's SSN on line 2. Where the claimant is filing a Request for Reconsideration-Disability Cessation on more than one SSN, all SSN's must be entered. (Where the claimant has received a cessation notice(s) on more than one entitlement, the request for reconsideration would generally be filed on all claims.) The beneficiary identification code (BIC) for title II and the type of claim code (TOC) for title XVI must always be shown after each SSN. Where there is more than one code for an SSN (e.g., concurrent title II DIB and title XVI individual claims) both codes must be shown. The spouse's name and SSN (when not the NH) need only be completed in SSI cases. On “type of benefit” line, check blocks to indicate all types of benefits on which the individual is requesting reconsideration - disability cessation.

C. Representative

Indicate the name and identifying information of claimant's representative, if any. Be sure to include the zip and area codes. It is important for the claimant to provide the name of the representative at the time of filing, if possible, so the representative can be notified of the time and place of the hearing well in advance.

D. Reason for Reconsideration Request

Describe as clearly as possible why the claimant feels he/she is still disabled. Try to relate the explanation as closely as possible to the basis for cessation on the personalized cessation notice. Go through the notice and find out specifically why the person believes he/she is still disabled or what part of the notice he/she thinks is wrong. Avoid writing “I am still disabled and cannot work;” this says nothing new. Any new explanation(s) or new impairment(s) should be specified. If the notice of determination is dated more than 65 days ago, a reason for not making the request earlier must be included.

E. Additional Information

List any information the person is submitting or wants to submit. Remind him/ her to submit any new information as early as possible in the disability hearing process. Waiting until the hearing to submit information may delay the decision because the claims folder might have to be sent back to the DDS to develop the new evidence.

F. Personal Appearance/Interpreter

Indicate if the individual wishes to appear at the hearing. Appearing includes a representative appearing on the claimant's behalf. If the claimant will be appearing, indicate if an interpreter is needed. If so, specify the language and check whether the individual will furnish his/her own interpreter or whether SSA needs to provide. Explain that the interpreter must be able to translate technical medical terminology and concepts. If the individual is unable to provide a qualified interpreter, SSA should provide the interpreter. If the individual insists on providing an interpreter who appears to be unqualified (e.g., a young child) prepare a Report of Contact for the claims folder explaining the situation. The DHU will ensure that a qualified interpreter is provided. If the individual does not wish to make a personal appearance, so indicate. When this block is checked, have the individual sign a Waiver of Right to Appear - Disability Hearing (SSA-773-U4). As shown in DI 12095.050, you will not need to complete all of the identifying information on the SSA-773-U4 when it is being completed in conjuction with an SSA-789-U4. Simply complete the name and claim number(s) and obtain the signature. (If an individual decides, subsequent to filing, to waive the appearance the entire SSA-773-U4 is completed.)

G. Signature

Either the claimant or his/her representative may sign the form. However a signature is not required to process the reconsideration request (see GN 03103.020D.). If we have a writing that clearly shows dissatisfaction with an initial determination and it clearly originated with the claimant, process the request without the signature. If the representative signs, either the "attorney" or "nonattorney" block should be checked, as appropriate. When the claimant signs and has a representative, insert the name and address of the representative. Obtain an SSA-1696-U4, Appointment of Representative, whenever none was previously filed for that representative (see GN 03910.040). Be sure to include all identifying information requested, including zip and area codes. If the individual's actual place of residence is different from the mailing address, record the actual residence on an SSA-795 statement. This is important for scheduling the hearing conveniently and for possible reimbursement for travel expenses. If the individual wishes to have the hearing held at a site other than a cite closest to his/her place of residence, take an SSA-795 statement providing the location requested and an explanation (e.g., temporary residence in another city for medical treatments). For foreign claims in which the claimant wants a personal appearance, take an SSA-795 statement indicating the hearing site requested. (Claimant's requests for hearing sites will be considered in relation to potential administrative costs. However, generally claimants will not have to travel more than 75 miles within the U.S. to reach the hearing site and therefore reimbursement for claimant travel will not generally be necessary.) Attach an SSA-795 statement concerning the scheduling of the hearing to the DHU-S copy of the SSA-789-U4 and forward to the DHU. Place a photocopy of the SSA-795 in the claims folder. In foreign and railroad claims, attach the SSA-795 to the SSA-789-U4 and forward to INTPSC or GLPSC with the claims folder.

H. SSA Use Only

1. Benefit Continuation, Spanish Notices, Impairment Code

Check the items which apply. If an item does not apply, enter N/A (not applicable). Do not leave these blocks blank. Check the benefit continuation block if the individual's benefits (payments) will be continuing. Check the Spanish Notices block if he/she meets the normal criteria for receiving Spanish notices. In the impairment code block: Indicate “A” if the individual alleges a mental impairment, the claims folder indicates a mental impairment or there is any indication that there may be a mental impairment. Indicate “B” if multiple impairments are alleged or may be involved. If both mental and multiple impairments are involved, enter both “A” and “B.” If neither mental nor multiple impairments are involved, enter N/A. It is important for DHU to have this information because hearings involving mental or multiple impairments need to have additional time scheduled.

2. DO, DDS and DHU Codes

Be sure to indicate the correct DO, DDS, and DHU Code. Always enter the servicing DO Code. If the request for reconsideration is filed in a DO that is not the individual's servicing DO, look up the servicing DO Code and indicate it on the SSA-789-U4. The servicing DO code also controls the appropriate DDS and DHU Code. It is important to show the servicing DO Code correctly because this code generally determines the hearing location. For railroad claims, be sure to show GLPSC as the DDS. For foreign claims, show INTPSC as the DO and DDS. When a claimant in a foreign claim waives the personal appearance, the DHU is OD. When there will be a personal appearance, the DHU depends on the hearing site requested by the claimant. DHU codes can be found in POMS, Part 8, Chapter 4.