TN 53 (08-95)

Exhibit 1 - Dixon Potential Class Membership Notice (English and Spanish Versions)

Exhibit 2 - Reply Form

Exhibit 3 - Acknowledgement Notice

Exhibit 4 - Sample Folder Alert

Exhibit 5 - Dixon Screening Sheet

Exhibit 6 - Dixon Screening Sheet Instructions

Exhibit 7 - Dixon Non-Class Membership Notice

Exhibit 8 - Notice of Determination (Not Disabled Based on Presumptions)

Exhibit I - Dixon Potential Class Membership Notice (English and Spanish Versions)

Social Security Administration

Important Information

DATE:

CLAIM NUMBER:

DI             DOC:

Telephone:

READ CAREFULLY - PLEASE RESPOND TO THIS NOTICE WITHIN 90 DAYS

We may have good news for you about your past claim for disability benefits. A recent court case called Dixon v. Shalala said that we may not have used the right rules when we denied claims or stopped disability payments.

WHAT YOU NEED TO DO

You can ask us to look at your claim again. If you want us to do this, fill out the enclosed reply form and send it to us now. You have 90 days from the day you receive this letter to do it, but don't wait. If you don't return the reply form, we will not be able to review your claim.

After we finish our review, we will send you a notice about our decision.

IF YOU NOW GET MONEY FROM - SOCIAL SECURITY

Even if you now get money from Social Security, we may owe you still more. Return the reply form within 90 days to ask us to review your claim.

IF YOU HAVE ANY QUESTIONS

If you have any questions, you may contact your local Social Security office. The address and phone number are printed at the top of this letter. If you call or visit an office, please have this letter with you. It will help us answer your questions.

Additionally, if you have someone helping you with your claim, you should contact him/her. You also may contact one of the following offices to ask for assistance with your claim:

Remainder of New York State:

• Greater Upstate Law Project (800)724-0490

   

Enclosures:
Reply Form and Envelope

Administracion Seguro Social

Información Importante

LEA CUIDADOSAMENTE - USTED SOLO TIENE 90 DIAS PARA RESPONDER A ESTE AVISO

Puede que nosotros tengamos buenas noticias para usted acerca de su reclamacion anterior de beneficios de incapacidad. Un caso de corte, reciente, Ilamado Dixon v. Shalala dice que no usamos las reglas correctas cuando le denegamos o cesamos de pagar beneficios de incapacidad.

¿Oue usted necesita hacer?

Usted nos puede pedir que revisemos su caso nuevamente. Si usted guiere que hagamos ésto, llene el formulario de respuesta que le incluímos, y devuélvalo ahora. Usted tiene 90 días, a partir del día en que reciba esta carta para hacerlo, pero no espere. Si usted no devuelve el formulario de respuesta, nosotros no podremos revisar su caso.

Tan pronto terminemos con la revisión, nosotros le enviaremos una carta con nuestra decisión.

Si usted recibe dinero de Seguro Social ahora

Aunque usted esté recibiendo dinero de Seguro Social ahora, es posible que todavía le debamos más. Devuelva el formulario de respuesta dentro de 90 días pidiéndonos que revisemos su caso.

Si usted tiene preguntas

Si usted tiene cualquier pregunta, se puede comunicar con su oficina local de Seguro Social. La dirección y número de teléfono se encuentran en la parte superior de esta carta. Si usted llama o visita la oficina, favor de tener esta carta con usted, pues nos ayudarla a responder sus preguntas.

Además, si usted tiene a alguien ayudándolo con su caso, usted se debe comunicar con é1 o ella. También, se puede comunicar con una de las siguientes oficinas, si necesita ayuda con su caso:

Residentes fuera de la Ciudad de NY

• Greater Upstate Law Project (800) 724-0490

   

Adjunto:

Formulario de Respuesta y Sobre

Exhibit 2 - Reply Form

SOCIAL SECURITY ADMINISTRATION

DIXON v. SHALALA REPLY FORM

IMPORTANT
RETURN THIS FORM WITHIN 90 DAYS TO REQUEST REVIEW OF YOUR CLAIM

IF YOU WANT THIS CLAIM REVIEWED, PLEASE SIGN AND DATE THIS FORM AND RETURN IT IN THE SELF-ADDRESSED, PREPAID ENVELOPE.

Enter the area code and the telephone number where we can call you.

(AREA CODE)            TELEPHONE NUMBER         

• CHECK THIS BLOCK AND WRITE YOUR ADDRESS ONLY IF IT IS DIFFERENT THAN SHOWN ABOVE.

ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)

• CHECK THIS BLOCK ONLY IF YOU HAVE A SOCIAL SECURITY CLAIM NUMBER THAT IS DIFFERENT FROM THE CLAIM NUMBER SHOWN ABOVE, AND ENTER THE OTHER NUMBER.

  .                       .
  SOCIAL SECURITY NUMBER

   

Privacy Act Notice

The Social Security Act (Sections 205(a) of title II, 702 of title VII, 1631 (e)(1)(A) and (B) of title XVI, and 1869(b)(1) and (c) of title XVIII) allows us to collect the information on this form. We will use the information to process your claim. You do not have to give us this information, but without it we may not be able to process your claim. Information may be disclosed to another person or to another governmental agency for the administration of the Social Security program or for the administration of programs requiring coordination with the Social Security Administration. Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security Offices. If you want to learn more about this, contact any Social Security office.

Si usted no entiende esta carta, llevela a la oficina de Seguro Social arriba mencionada para que se la expliquen.

  Exhibit 3 - Acknowledgement Notice

Social Security Administration

Important Information

DATE:

CLAIM NUMBER:

DOC:

Telephone:

We are writing to tell you that we received your Dixon v. Shalala response form asking for a review of our earlier decision that you were not disabled.

We expect to receive many requests for this review and it may take some time before we look at your file. When we start the review, we will decide if you are a member of the “class” of individuals who are entitled to relief in connection with this lawsuit.

*

If you are a member of the class of individuals entitled to relief, we may ask you for any additional evidence you may want to submit.

*

If you are not a class member entitled to relief, we will send you a notice telling you why and advising you of any other rights you may have.

If you have any questions, you may contact your Social Security office. The address and phone number are printed at the top of this letter. If you have someone helping you with your claim, you should contact him/her. You also may contact one of the following offices to ask for assistance with your claim:

If you call or visit a Social Security office, please have this letter with you. It will help us answer your questions.

Si usted habla espanol y no entiende esta carta, favor de llevarla a la oficina de Seguro Social arriba mencionada para que se la expliquen.

Exhibit 4 - Sample Folder Alert

DI 000000     DI   00000

DIXON COURT CASE FLAG/ALERT

REVIEWING PSC DOC TOE ALERT DATE RESPONSE DATE OLD BOAN/PAN 

OFFICE 

         Y    000  000   00/00/00    00/00/00 

SSN (BOAN or PAN)    NAME    BIRTH DATE     REFERENCE# 

000-00-0000   BEVERLY G GEE  00/00/0000     000000000 

                    FOLDER LOCATION INFORMATION 

CAN / HUN BIC/MFT CATG TITLE CFL CFL DATE ACN 

000-00-0000   A        CON 

000-00-0000   DI       XVI/CON 

PAYEE ADDRESS 

BEVERLY G GEE 

734 BONVIEW DR 

ELMIRA NY 14905 

SHIP TO ADDRESS: 

SSA, ODIO 

CLASS ACTION SECTION 

ATTENTION: DIXON COORDINATOR 

P.O. BOX 17369 

BALTIMORE, MD 21298-0050 

SPECIAL INSTRUCTIONS: 

IF CLAIM IS PENDING IN OHA, THEN SHIP FOLDER TO: 

OFFICE OF HEARINGS AND APPEALS 

OFFICE OF APPELLATE OPERATIONS 

ONE SKYLINE TOWER, SUITE 701 

5107 LEESBURG PIKE 

FALLS CHURCH, VA 22041-3200 

ATTN: OAO CLASS ACTION COORDINATOR 

Exhibit 5 - Dixon Screening Sheet

13. If you checked “No” in blocks 7, 8, 9, or 10 or “Yes” in blocks 11 or 12, the individual is not a Dixon class member entitled to relief. Check the “Nonmember/Member Not Entitled to Relief” block (F) in item 6.a. Enter the screenout code in item 6.b. as follows:

Exhibit 6 - Dixon Screening Sheet Instructions

DIXON SCREENING SHEET INSTRUCTIONS

COMPLETE ONLY ONE SCREENING SHEET PER INDIVIDUAL IN DUPLICATE, EVEN IF THE CLAIMANT RECEIVED MULTIPLE DETERMINATIONS WITHIN-THE CLASS DATES. HOWEVER, THE SCREENING SHEET PROVISIONS MUST BE CONSIDERED SEPARATELY FOR EACH CLAIM. A CLASS MEMBER WHO RECEIVED MULTIPLE DETERMINATIONS IS ELIGIBLE FOR READJUDICATION ONLY ON THOSE CLAIMS MEETING ALL CLASS MEMBERSHIP REQUIREMENTS. PLEASE BE AWARE THAT YOU MUST CONSIDER ALL CLAIMS DECIDED DURING THE PERIOD COVERED BY THE COURT ORDER (i.e., June 1, 1976 through July 19, 1983) WHEN MAKING THE CLASS MEMBERSHIP DETERMINATION.

Item 1: Enter the claimant's own SSN. This will be used to identify the claimant in CATS.

Item 2: Enter the claimant's name.

Item 3: Enter the claimant's date of birth (mm/dd/yy). This will also be used to identify the claimant in CATS.

Item 4: Fill in the appropriate account numbers, including BIC and/or ID, under which the claimant filed for benefits.

Item 5: Fill in the actual date that the screening is completed.

Item 6: Fill in the appropriate blocks once screening is completed, as directed in Items 13 and 14. When multiple claims are screened out for different reasons, use the screenout code for the claim with the earliest date of the Dixon application. If the screenout is later protested, the claimant will be protected with the earliest protective filing date.

Item 7: This is self-explanatory. If there is no record of a possible Title II or XVI claim number, answer this question “NO” and enter the appropriate screenout code (07) as directed in Item 13. Check block F in Item 6. a. and fill in the screen out code in Item 6. b.; sign the screening sheet. Complete the “Nonmember/Member Not Entitled to Relief” Notice as indicated below under Instructions if Claimant is Determined to be a Non-class Member or a Class Member Not Entitled to Relief, checking off Item 2. as the reason that the individual is not entitled to any relief. In the event that the individual furnishes another SSN, or evidence of having filed a claim under the original number, which has a claim(s) denied/ceased in the timeframe, rescreen the case. Send the Revised Decision Notice if the claim is screened in.

Item 8: Review the Dixon alert, related queries (FACT, SSIRD, etc.) and claim file(s). Screen for date of decision, not application.

The term “final” refers to the date of the administrative determination/decision that became the binding decision of the Secretary pursuant to 20 CFR SS 404.905, 404.921, 404.955, 404.792, 404.981, 416.1405, 416.1421, 416.1455, 416.1472, and 416.1481. It does not mean that a class member must have exhausted administrative remedies under §§ 205(g) and (h) of the Social Security Act, 42 USC § 405(g) and (h). Although not the “final decision” of the Secretary, an Appeals Council denial of a request for review constitutes a final determination and controls for the purposes of class membership screening. If the claimant appealed a determination/decision made within the class membership timeframe and then received an administrative determination/decision made after July 19, 1983, the claimant is not a class member entitled to relief.

When the claim file has been destroyed or declared lost, determine if the claim may be screened out solely on the basis of information shown on the queries (see DI 42521.020.B.4.a.).

If the answer is “NO”, enter the appropriate screenout code (08) as directed in Item 13. Check block F in Item 6. a. and fill in the screen out code in Item 6. b. Sign the screening sheet.

Item 9: Screen for residency at the time of the final determination/decision. Review the folder or alert package for indications of New York State residency at the time the claim was decided at the highest level of administrative review. If the answer is “NO”, enter the appropriate screenout code (09) as directed in Item 13. Check block F in Item 6. a. and fill in the screen out code in Item 6. b. Sign the screening sheet.

Item 10: Screen to determine whether there was a final determination/decision made on the basis of a not severe impairment or that the impairment was only “slight”. To answer this question, in cases finally decided at the initial or reconsideration level, start with a review of the Form SSA-831U5, Form SSA-3687-U2 or the Form SSA-3428-U2 for denial cases or a review of the SSA-832/833-U5 for cessation cases.

Review the file(s) and/or queries (e.g. FACT, SSIRD) to determine whether the claimant received a denial/cessation decision on any claim(s) at step 2 of the sequential evaluation process. Look in Item 22 of the Form SSA-831-U5. In a CDR case, read the rationale to determine the reason for the cessation on the-SSA 832/833. In a DHU or OHA case, read the decision to determine the basis for the denial or cessation. Use the latest date on the Form SSA-831-U5, or other denial form, or the date of a DHU or OHA decision as the date of the final determination/decision.

If the regulation basis code reflects a not severe determination (e.g., F1 and F2 for Title II cases or N30 and N41 for Title XVI cases) check “Yes” in Item 10. If not, then check “NO” and enter the appropriate screenout code (10) as directed in Item 13. Check block F in Item 6. a. and fill in the screen out code in Item 6.b.; sign the screening sheet. (See POMS DI 26510.045 for a description of the Reg. Basis Codes).

NOTE: If an initial or reconsideration level determination/decision was made on the basis that the claimant had a not severe impairment(s), but the final determination/decision on appeal was not based on a finding that the impairment(s) was not severe, the claimant is not a class member entitled to relief.

Item 11: Check for a final administrative decision made during the class member timeframe. Look for a less thanfully favorable final Title II or Title XVI determination/decision or termination issued by the NYODD or OHA, on an appeal of a NYODD determination, that was appealed to a Federal court and either affirmed or denied by the court.

NOTE: For informational purposes, the period within which an appeal of a district court decision may be filed is 60 days from the date of entry of judgment. Therefore, a district court decision entered on October 2, 1989 became final and unappealable on December 2, 1989, the 61st day after entry of judgment if no appeal was filed.

If the answer to Item 11 is “Yes” and no other claims qualify for Dixon DDS/OHA review, enter the appropriate screenout code (11) as directed in Item 13. Check block F in Item 6.a. and fill in the screen out code in Item 6.b. Sign the screening sheet.

NOTE: For class membership screening purposes, a Federal court remand is not a decision, and is not a valid reason for denial of class membership,.

Item 12: This exception applies only if the individual has received all benefits to which s/he could be entitled based on the potential class member claim, or has received a denial decision which covers the entire period covered by the potential class member claim.

Determine whether benefits were subsequently allowed or continued from the earliest possible entitlement date, cessation date, or control date. Be sure to consider earlier eligibility for Medicare when determining if the subsequent decision is fully favorable. The allowance, continuance or denial could have either been on the same claim or on a subsequent application. Review the file(s) and queries (e.g., FACT, SSIRD) to determine if benefits were subsequently allowed or continued. If yes,

• in title II cases, check the subsequent award/continuation for first month of entitlement.

• in title XVI cases, check the subsequent award/continuation for the first month of eligibility.

Identify the earliest Dixon claim/termination. Determine the earliest month benefits could have been paid based on the Dixon alleged onset and the Dixon application or termination date.

Compare the earliest possible Dixon benefit date with the subsequent award or continuation dates. If the dates are the same and the allowance or continuation was fully favorable (not a closed period allowance), and no other claims qualify for Dixon DDS/OHA review, the answer to Item 12 is “Yes”. In addition, if the earliest Dixon claim was a termination, and the individual already received a subsequent decision review on that potential class member claim and that decision review covered the entire period covered by the potential class member, then, the answer to Item 12 is also “Yes”. Enter the appropriate screenout code (12) as directed in Item 13. Check block F in Item 6. a. and fill in the screen out code in Item 6. b. Sign the screening sheet.

NOTE: If full retroactive benefits were not paid, check to see if the later award established an onset that would allow payment back to the first possible month under the Dixon claim. If the earliest possible onset was established, but full retroactive benefits were not paid, enter, “Dixon Court Case - Retroactive Benefits Due Based On Earlier Application” on a route slip. Sign and date the screening form. If ODIO or the PSC is screening the case, route the case to a claims authorizer for processing the Title II claim, or the appropriate FO, for a Title XVI claim, for the preparation of an amended award. Follow DI 42521.020.B.6. If the DDS is screening the case, follow DI 32521.015.B.5.

Instructions if Claimant is Determined to be a class Member Entitled to Relief

1. Check the “Member” block in Item 6. a. of the screening sheet.

2. Sign and date the screening sheet. Enter the name of the screening component.

3. Show the dates of all applications screened and the dates of the final administrative action on each.

4. Retain the original screening sheet in the folder. Send a copy to:

5. Route per DI 42521.030 (or DI 32521.030.6. if screening sheet is prepared in the DDS) for class member cases.

NOTE: OHA screeners, See HALLEX Temporary Instruction (TI) 5-XXX, Parts       for instructions.

Instructions if Claimant is Determined to be a Non-class Member or a Class Member Not Entitled to Relief

1. Check the “Non-member/Member Not Entitled to Relief” block in Item 6. a. and enter the appropriate screen-out code in Item 6. b.

2. Follow Items b. - d. above.

3. Prepare the “Non-Class Member” notice and send as follows:

   • Original to the claimant

   • Copy to class counsel

   • Copy in file

   • Copy to claimant's representative, if there is one

4. Route per DI 42521.030 (or DI 32521.030.6. if the screening sheet is prepared in the DDS).

   NOTE: OHA screeners, See HALLEX Temporary Instruction (TI) 5-XXX,
   Parts          for instructions.

Exhibit 7 - Dixon Non-Class Membership Notice

Social Security Administration

Important Information

DATE:

CLAIM NUMBER:

DOC:

Telephone:

You asked us to review your earlier claim for disability benefits under the Dixon v. Shalala court order. We have looked at your case and have decided that you are not a Dixon class member entitled to relief. This means that we will not review our earlier decision that you were not disabled. The reason that you are not a class member entitled to relief under the Dixon court decision is checked below.

Why You Are Not A Class Member Entitled to Relief

You are not a Dixon class member entitled to relief because:

We Are Not Deciding If You Were Disabled

It is important for you to know that we are not making a decision about whether you were disabled at the time of your earlier claim. We are deciding only that you are not a Dixon class member entitled to relief.

If You Do Not Agree With This Determination

If you want us to review our determination that you are not entitled to relief under the Dixon case, you may contact us in writing. You also may contact one of the following offices to ask for assistance with your claim:

Outside of New York City:

• Greater Upstate Law Project (800) 724-0490

They will answer your questions about entitlement to relief.
YOU MUST DO THIS WITHIN 90 DAYS OF RECEIVING THIS NOTICE.

If You Have Any Questions

If you have any questions, you may contact your Social Security office. The address and phone number are printed at the top of this letter. If you call or visit an office, please have this notice with you. It will help us answer your questions.

Also, if you have someone helping you with your claim you should contact him/her.

Si usted habla espanol y no entiende esta carta, favor de llevarla a la oficina de Seguro Social arriba mencionada para que se la expliquen.

cc: The Legal Aid Society

Exhibit 8 - Notice of Determination (Not Disabled Based on Presumptions)

Social Security Administration

Important Information

DATE:

CLAIM NUMBER:

DOC:

Telephone:

You have asked us to review your earlier claim for disability benefits under the Dixon v. Shalala court order. We have reviewed your case and have decided that you are not disabled under the terms of the Dixon court order.

Under the terms of the Dixon court order, SSA must make reasonable efforts to retrieve records for the purpose of readjudicating class members' claims. However, if the records of a class member cannot be located, the Dixon court order allows SSA to make certain presumptions about whether or not the class member was disabled during the Dixon time frames.

We have been unable to locate your earlier application and the medical evidence which you previously filed. Consequently, under the terms of the Dixon court order, we have applied the court ordered presumptions in your case and have determined that you are not disabled.

The reason we determined that you are not disabled and, therefore, not entitled to any relief under the Dixon court decision is checked below.

Why You Are Not Disabled and Not Entitled to Relief

You are not disabled and not entitled to any relief under Dixon because:

This review does not affect any checks that you may be getting now based on any later application(s) you may have filed.

If You Do Not Agree With This Determination

We hope this satisfactorily explains the reason for the determination in your case. If you still believe that this determination is not correct, you may request a hearing before an Administrative Law Judge of the Office of Hearings and Appeals. If you want a hearing, you must request it not later than 60 days from the date you receive this notice. You should make your request through any Social Security office. Read the enclosed leaflet for a full explanation of your right to appeal.

In addition, you have the right to submit new evidence about what your medical condition was at the time of the old decision. You should submit any such evidence at the time that you request a hearing. SSA will consider any evidence you may wish to submit.

If You Have Any Ouestions

If you have any questions, call us at 1-800-772-1213, or call your local Social Security office at 1-         . We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

Social Security Administration
              
              
              

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may wish to call ahead to make an appointment. This will help us to serve you more quickly when you arrive at the office.

Also, if you have someone helping you with your claim you should contact him/her.

Si usted habla espanol y no entiende esta carta, favor de llevarla a la oficina de Seguro Social arriba mencionada para que se la expliquen.

cc: The Legal Aid Society

Enclosure: SSA-10281

NOTE: Please do not forward completed folders to The Class Action Section (CAS) located in Baltimore, Maryland. Upon completion of a case, the folder should be forwarded to the appropriate storage facility (PSC, WBDOC, ODO). CAS does not house completed folders.