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

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 SSA-3441, Disability Report - Appeal, 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.

Below you will find Form in Portable Document Format (PDF). To print the PDF version, you will need the Adobe Acrobat reader software. If you do not already have this special software, see our page on downloading and printing PDF documents.

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