Request for Hearing by Administrative Law Judge

If you do not agree with the reconsideration determination we made on your claim, you may file a request for hearing before an Administrative Law Judge (ALJ). To request a hearing, you may use this form or write a letter.

If you are not sure this is the form you should use, the Notice of Reconsideration (reconsideration determination) will tell you that to appeal our determination you should request a hearing before an ALJ. If the notice does not say this, or if you still are not sure this is the form you should complete, call 1-800-772-1213 or your local Social Security office and they will help you to complete the right appeal form.

If you are requesting a hearing on the denial of a claim for disability benefits, you must complete and sign additional forms. These forms are the HA-4486, Claimant's Statement When Request for Hearing is Filed and the Issue is Disability, and SSA-827, Authorization to Disclose Information to SSA. You should also complete an HA-4631, Claimant's Recent Medical Treatment, and an HA-4632, Claimant's Medications. If you have worked since you filed your application for disability benefits, complete an HA-4633, Claimant's Work Background.

You may also need to complete a form SSA-1696, Appointment of Representative, if you are appointing a representative. Your representative should also sign the SSA-1696 before you send it to us.

You must file your appeal within 60 days from the date you got the reconsideration determination. We assume you got the reconsideration determination within 5 days of the date shown on that notice unless you can show us you did not get it within the 5-day period.

Time to Submit New Evidence: You should submit any new evidence you want the ALJ to consider within 10 days of the date that you file this request. If you will not be able to submit the evidence within 10 days, you must ask the ALJ for an extension of time to submit evidence.

How to Obtain the Form

After you download the Adobe Acrobat Reader, come back to this page and download the PDF version of the HA-501:

Request for Hearing by Administrative Law Judge, Form HA-501

How to Complete the Form

1. NAME OF CLAIMANT: Enter your name or the name of the person on whose behalf you are filing the request for hearing.

2. NAME OF WAGE EARNER: If you receive or are applying for Social Security benefits on someone else's work record, enter that person's name.

3. SOCIAL SECURITY CLAIM NUMBER: The Social Security claim number depends on the type of claim you are appealing. If the appeal is on a claim for:

   • Social Security benefits on your work record, enter your Social Security number (SSN).

   • Social Security benefits on someone else's work record (that is, the wage earner in 2.), enter that person's SSN.

   • Social Security benefits on your work record and on the wage earner's work record, enter both SSNs.

   • Supplemental Security Income (SSI), enter your SSN. ·

   • Social Security benefits on the wage earner's work record and SSI, enter both SSNs.

4. SPOUSE'S CLAIM NUMBER: If you are appealing a reconsideration determination in an SSI or concurrent (SSI and Social Security) claim, enter the your spouse's SSN.
   

5. I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE: Tell us why you disagree with the reconsideration determination. If you need additional space, you can attach a separate sheet of paper. Include your name and Social Security claim number on any additional pages, and on all correspondence, you send to us.

6. ADDITIONAL EVIDENCE: If you have additional evidence to submit, check this block and enter the name and address of the source. (For example, if you have additional evidence to submit from your treating doctor, you would enter his or her name and address.)

7. APPEARANCE AT THE HEARING: You must check one of the blocks in this item to tell us if you want to appear at a hearing. If you do not want to appear, you must also complete form HA-4608, Waiver of Your Right to Personal Appearance Before an Administrative Law Judge.

8. Signature: Sign and date the form and fill in your address and telephone number. If you are filing on behalf of a child or an incompetent adult, enter your relationship to the claimant (for example, parent or legal guardian).
9. Representative's Signature: If you have a representative he or she should sign and complete this section. Do not delay filing your request for hearing to get your representative's signature. If you do not have a representative and would like someone to represent you (for example, an attorney), your local Social Security office can provide you with a list of representatives for your area.

Do not complete anything below the line that says "TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION - ACKNOWLEDGEMENT OF REQUEST FOR HEARING." We will complete this part of the form when we receive it.

Where To Send The Form