Predetermination Notice

Individual is not denied or ceased for failure without first sending a predetermentation notice

EXHIBIT - MODEL LETTER

We are writing to you on behalf of the Social Security Administration in reference to your claim for disability insurance benefits.

A person may qualify for disability insurance benefits only if he or she is unable to perform any substantial gainful work due to a medical impairment which has lasted, or can be expected to last for a continuous period of at least 12 months. However, a person may not be considered to be disabled if he or she refuses to follow prescribed treatment that can be expected to prevent his or her condition from being disabling for at least 12 months.

The evidence now in your file indicates that you are failing without justifiable cause to undergo prescribed (tell what treatment—e.g., back surgery, eye surgery) which could be expected to restore your ability to work. For this reason we may be required, under the law, to determine that you are not under a disability. If you plan to follow the treatment prescribed, it is important that you let us know within 30 days.

If we do not hear from you within 30 days of the date of this notice, we will assume that you have decided not to follow the treatment prescribed for you. In this event, a formal determination will be made based on the evidence already in file and your claim will be denied. Such a denial may also result in the loss of future rights or a decrease in the amount of benefits payable.

If you have any questions, or if you have decided to follow the treatment prescribed, please write (insert title and address of DDS) as soon as possible or call (name if contact and phone number).