Form HA-501 at a glance
What it is: Form HA-501 (06-2022) is the REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE of the Office of Hearings Operations.
Who signs: Box 7 is the CLAIMANT SIGNATURE (OPTIONAL), with the DATE.
A filled-in Form HA-501 example: a claimant asks for a hearing
How to fill out Form HA-501, box by box
Claimant Name, Claimant SSN and Claim Number
Enter 1. Claimant Name, 2. Claimant SSN and 3. Claim Number, if different.
I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE
In box 4, enter: I disagree with the determination because:
I have additional evidence to submit, and Do not complete if the appeal is a Medicare issue
5. I have additional evidence to submit. Yes No. 6. Do not complete if the appeal is a Medicare issue. Otherwise, check one of the blocks.
I wish to appear at a hearing.
I do not wish to appear at a hearing and I request that a decision be made based on the evidence in my case. (Complete Waiver Form HA-4608)
Enter the name and source of additional evidence, if not included.
Submit your evidence to the hearing office within 10 days. Your servicing Social Security office will provide the hearing office's address. Attach an additional sheet if you need more space.
CLAIMANT SIGNATURE (OPTIONAL) and NAME OF REPRESENTATIVE (if any)
Box 7 is the CLAIMANT SIGNATURE (OPTIONAL), with the DATE.
Under residence address, enter the address, city, state, zip code, telephone number and fax number.
Box 8 is the name of the representative (if any), with the address, city, state, zip code, telephone number and fax number.
Representation: You have a right to be represented at the hearing. If you are not represented, your Social Security office will give you a list of legal referral and service organizations. If you are represented, complete and submit form SSA-1696 (Appointment of Representative) unless you are appealing a Medicare issue.
More rules for Form HA-501
9. Request received on, in the ACKNOWLEDGMENT OF REQUEST FOR HEARING, is TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION.
10. Was the request for hearing received within 65 days of the reconsidered determination? If no, attach claimant's explanation for delay and supporting documents if any.
SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
You can find your local Social Security office through SSA's website at www.socialsecurity.gov, or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
Common questions about Form HA-501
What is form HA 501?
Form HA-501 (06-2022) is the REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE of the Office of Hearings Operations. An Administrative Law Judge of the Social Security Administration's Office of Hearings Operations or the Department of Health and Human Services will be appointed to conduct the hearing or other proceedings in your case. You will receive notice of the time and place of a hearing at least 75 days before the date of hearing from the Social Security Administration, and 20 days before the date of hearing from the Department of Health and Human Services.
Where do I file it?
Take or mail the completed original to your local Social Security office, the Veterans Affairs Regional Office in Manila or any U.S. Foreign Service post and keep a copy for your records.
Sources
[1] Form HA-501 (06-2022), Request for Hearing by Administrative Law Judge, Social Security Administration (the Official source link on this page).
