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SSA-1490—Request for Payment. (For use by

patient or physician to request payment

for medical expenses.)
SSA-1554-Provider Billing for Patient Sery-

ices by Physicians. (For use by hospitals
for payment for services provided by

hospital-based physicians.)
SSA-1556—Prepayment Plan for Group Medi-

cal Practices Dealing Through a Carrier.
(For use by organizations (which have
been determined to be Group Practice
Prepayment Plans for Medicare pur-
poses) for reimbursement for medical

services provided to beneficiaries.)
SSA-1660_Statement of Person Requesting

Supplementary Medical Insurance Pay-
ment on Behalf of Estate. (For use in
requesting amounts payable under title

XVIII to a deceased beneficiary.)
SSA-1966–Health Insurance Card. (This

card is issued to a person entitled to
benefits under the health insurance for
the aged program and designates
Whether he is entitled to hospital in-
surance benefits or supplementary medi-

cal insurance benefits or both.)
132 FR. 18030, Dec. 16, 1967, as amended at
33 F.R. 11280, Aug. 8, 1968]
$422.515 Forms used for withdrawal,

reconsideration and other appeals,

and appointment of representative. The following is a list of forms prescribed by the Social Security Administration for use by the public to request a withdrawal of an application, a reconsideration of an initial determination, a hearing, a review of a hearing examiner's decision, or for appointment of a representative: OA-C521-Request for Withdrawal of Ap

plication. (For use by an individual to cancel his application.) -C561_Request for Reconsideration. (For use by an individual who disagrees with an initial determination concerning (a) entitlement to benefits or any other right under title II of the Social Security Act, or (b) entitlement to hospital insurance benefits or supplementary medical insurance benefits under title XVIII of the Act, or (c) the amount of hospital insurance benefits under such title XVIII to obtain a review of his case. See § 422.140 for a discussion

of the reconsideration procedure.)
HA-501-Request for Hearing. (For use by

an individual or institution to obtain
a hearing before a hearing examiner of
the Social Security Administration. See
§ 422.203 for a discussion of the hearing

procedure.)
HA-512-Appointment of Representative.

(For use by person other than an at-
torney authorized by a claimant to act
for him in a claim or related matter.)

HA-512.1—Notice by Attorney of Appoint

ment as Representative. (For use by an attorney authorized by a claimant to act

for him in a claim or related matter.) HA-520—Request for Review of Hearing Ex

aminer's Action. (For use by an individual or institution to obtain a review of a decision by a hearing examiner of the

Social Security Administration.) § 422.520 Forms related to maintenance

of earnings records. The following forms are used by the Social Security Administration and by the public in connection with the maintenance of earnings records of wage earners and self-employed persons: SS-4-Application for Employer Identifica

tion Number. SS-4A-Agricultural Employer's Application.

(For use by employers of agricultural workers to request an employer identi

fication number under the FICA.) SS-5--Application for Social Security Num

ber (or Replacement of Lost Card). SS-15—Certificate Waiving Exemption From

Taxes Under the FICA. (For use by certain nonprofit organizations requesting

coverage of its employees.) SS-15a—List of Concurring Employees. (To

be signed by each employee who concurs
in the filing of the Certificate Waiving
Exemption From Taxes Under the FICA,

Form SS-15.)
OASI-21—Social Security and Your House-

hold Employee. (For use by employers
of household workers to request infor-
mation from the District Director of In-
ternal Revenue regarding filing em-

ployee tax reports.)
OA-702—Account Number Card.
OA-702.1—Duplicate Account Number Card.
Form 2031-Waiver Certificate To Elect So-

cial Security Coverage for Use by Min-
isters, Certain Members of Religious
Orders, and Christian Science Practi-

tioners. Form 4029—Application for Exemption From

Tax on Self-Employment Income, Claim for Refund, and Waiver of Benefits. (TO be completed by self-employed individuals who are members of certain recognized religious sects (or division thereof) and do not wish to pay FICA taxes or participate in the programs pro

vided under titles II and XVIII.) Form 4361-Application for Exemption From

Self-Employment Tax for Use By Min-
isters, Members of Religious Orders, and

Christian Science Practitioners.
Form 4415—Election To Exempt From Self-

Employment Coverage Fees Received by
Certain Public Officers and Employees
of a State or a Political Subdivision

Thereof.
OAAN-5028—Temporary Account Number

Card.

OAAN-7003_Request for Change in Social

Security Records. (For use by an individual to change information given on original application for an account num

ber.) OAR-7004_Request for Statement of Earn.

ings. (For use by worker to obtain a statement of earnings recorded in his

earnings record.) OAR-7008—Request for Correction of Earn

ings Record. (For use by an individual who wishes to have his earnings record

revised.) SSA-7011-Statement of Employer. (For use

by an employer to provide evidence of wage payments in cases of a wage dis. crepancy in an individual's earnings

record.) (32 F.R. 18030, Dec. 16, 1967, as amended at 33 F.R. 11280, Aug. 8, 1968) $ 422.525 Where applications and other

forms are available. All applications and related forms prescribed for use in the programs administered by the Social Security Administration pursuant to the provisions of titles II and XVIII of the Act are printed under the specifications of the Administration and distributed free of charge to the public, institutions, or organizations for the purposes described therein. All prescribed forms can be obtained upon request from any social security district office or branch office (see $ 422.5). Forms appropriate for use in requesting payment for services provided under the health insurance for the aged programs can also be obtained from the intermediaries or carriers (organizations under contract with the Social Security Administration to make payment for such services) without charge. Form 2031 (Waiver Certificate To Elect Social Security Coverage for Use by Ministers, Certain Members of Religious Orders, and Christian Science Practitioners), Form 4029 (Application for Exemption From Tax on Self-Employment Income, Claim for Refund, and Waiver of Benefits), Form 4361 (Application for Exemption From Self-Employment Tax for Use

by Ministers, Members of Religious Orders, and Christian Science Practitioners), Form 4415 (Election To Exempt From Self-Employment Coverage Fees Received by Certain Public Officers and Employees of a State or a Political Subdivision Thereof), Form SS4 (Application for Employer Identification Number), Form SS-4A (Agricultural Employer's Application for Identification Number), Form SS-5 (Application for Social Security Number (or Replacement of Lost Card)), Form SS-15 (Certificate Waiving Exemption From Taxes Under the FICA), and Form SS-15a (List of Concurring Employees) can also be obtained without charge from offices of the Internal Revenue Service. For other offices where applications and certain other forms can be obtained, see Subparts B and C of this Part 422. (33 F.R. 11280, Aug. 8, 1968] $ 422.527 Private printing and modifica.

tion of prescribed applications and

other forms. Any person, institution, or organization wishing to reproduce, duplicate, or privately print any application or other form prescribed by the Administration should obtain the prior approval of the Administration. Requests for approval to so reproduce any prescribed form must be in writing and include the reason or need for such reproduction, the intended user of the form, the proposed modifications, if any, the proposed format, with printing or other specifications, the type of automatic data processing machinery (e.g., printer, burster, mail handling), if any, for which the form is being designed, estimated printing quantity, estimated cost per thousand, estimated annual usage, and such other pertinent information as may be required by the Administration. All requests are to be forwarded to: Social Security Administration, Printing and Records Management Branch, Baltimore, Md. 21235. [33 F.R. 11281, Aug. 8, 1968]

CHAPTER IV-EMPLOYEES' COMPENSATION APPEALS BOARD, DEPARTMENT OF LABOR

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PART 501-RULES OF PROCEDURE Sec. 501.1 Definitions. 501.2 Scope and applicability of rules;

composition and jurisdiction of

the Board. 501.3 Application for review. 501.4 Transmittal of record. 501.5

Oral argument. 501.6 Decisions. 501.7 Petition for reconsideration. 601.8 Docket of proceedings; inspection of

docket and records. 501.9 Regulation of proceedings. 601.10 Number of copies of pleadings and

related documents; service. 501.11 Appearances. 501.12 Intervention. 501.13 Place of proceedings.

AUTHORITY: The provisions of this part 501 issued under sec. 32, 39 Stat. 749, 5 U.S.C. 8145; sec. 3, Reorganization Plan No. 2 of 1946, 60 Stat. 1095; 8 CFR 1948-48 Comp., p. 1064; sec. 2, Reorganization Plan No. 19 of 1950, 64 Stat. 1272; 3 CFR 1949-53 Comp., p. 1010.

SOURCE: The provisions of this part 501 appear at 27 F.R. 12186, Dec. 8, 1962, unless otherwise noted. $ 501.1 Definitions.

(a) “Act” means the Federal Employees' Compensation Act and any statutory extension or application there

(e) "Party" means any person admitted and named as a party on the docket of the Board, including any intervenors.

(f) “Counsel” includes any person who is a member in good standing of the bar of the Supreme Court of the United States or the highest court of any State, territory, or the District of Columbia. [27 F.R. 12186, Dec. 8, 1962, as amended at 29 FR. 13519, Oct. 1, 1964) $ 501.2 Scope and applicability of rales:

composition and jurisdiction of the

Board. (a) The regulations in this part provide the rules of practice of the Board in hearing and deciding appeals from final decisions of the Bureau.

(b) The Board consists of three members appointed by the Secretary of Labor, one of whom is designated as Chairman of the Board and administrative officer.

(c) The Board has jurisdiction to consider and decide appeals from the final decision of the Bureau in any case arising under the Act. The Board may review all relevant questions of law, fact, and discretion in such cases. There shall be no appeal with respect to any interlocutory matter disposed of by the Bureau during the pendency of a case. The review of a case shall be limited to the evidence in the case record which was before the Bureau at the time of its final decision. § 501.3 Application for review.

(a) who may file. Any person adversely affected by a final decision of the Director, or his duly authorized representative, may file an application for review of such decision by the Board.

(b) Place of filing. Any application for review shall be filed with the Clerk of the Board, Employees' Compensation

of.

(b) "Board” means the Employees' Compensation Appeals Board.

(c) "Bureau” means the Bureau of Employees' Compensation and in the case of employees of the Canal Zone Government and of the Panama Canal Company, the Governor of the Canal Zone.

(d) "Director” means the Director of the Bureau and in the case of employees of the Canal Zone Government and of the Panama Canal Company, the Governor of the Canal Zone.

Appeals Board, U.S. Department of view and any brief or supporting stateLabor, Washington 25, D.C.

ment accompanying it. Within 30 days (c) Form of application; contents. An from the date of such service, the Diapplication for review should be filed rector shall transmit to the Board the with the Board upon Form AB-1 (Appli record of the proceeding to which the cation for Review). Any application application refers and such statement made without the use of the form shall in support of his decision or other pleadcontain the following information: The ing as he may consider necessary, but full name and address of the applicant, on application of the Director, the Board the name of the injured or deceased em may in its discretion extend such time. ployee, the employing establishment, the

$ 501.5 Oral argument. case file number assigned to the case by the Bureau, a description of the par (a) Notice. Whenever any party reticular injury involved, the date of the quests an opportunity to present oral injury, the place of injury, and the date

argument the Board shall schedule the of the decision being appealed. If the

case for argument. Each party shall be applicant is being represented by an notified at least ten days before the date other person in the proceeding, the name of argument. The notice shall state the and address of such representative should issues to be heard, as determined by the be stated. Each application shall in

Board. clude a succinct statement indicating

(b) Time allowed. Generally not more the contentions of the applicant and than 1 hour shall be allowed for oral describing with particularity any find

argument by any party although in apings of fact, conclusions of law, or ex

propriate cases the Board may in its ercise of (or failure to exercise) discre

discretion extend or shorten the time altion complained of. Any application con

lowed. taining incomplete information shall be

(c) Failure to respond to notice. returned to the applicant with a descrip

Failure to respond to a notice of oral tion of the additional information needed

argument shall not prejudice the rights and a reasonable opportunity for fur

of any party to the proceeding. The nishing any such information shall be

Board in its discretion may set the case allowed.

for further argument upon notice or it (d) Time for filing. (1) Except as

may proceed to dispose of the appeal provided in subparagraph (2) of this

pursuant to $ 501.6. paragraph, any application for review by a person residing within the United § 501.6 Decisions. States or Canada must be filed within

(a) The decision of the Board shall 90 days from the date of issuance of the

contain a written opinion setting forth final decision of the Director, and any

the reasons for the action taken and an application for review by a person re

appropriate order. The decision may siding outside the United States or Can

consist of affirmance, reversal, remand ada must be filed within 180 days from

for further development of the evidence, the date of issuance.

or other appropriate action. A copy of (2) For good cause shown, the Board

the decision shall be sent by the Board may in its discretion waive a failure to

to all parties in interest. The case record file an application within the time limita

shall be returned to the Director with a tions provided in subparagraph (1) of this paragraph, but for no longer than

copy of the decision. one year from the date of issuance of

(b) A decision of not less than two the final decision of the Director.

members shall be the decision of the (3) The date of filing of an applica Board. tion for review shall be the date upon (c) The decision of the Board shall be which the application is received by the final as to the subject matter appealed Board.

and such decision shall not be subject (e) Briefs and supporting statements.

to review, except by the Board. Any application for review may be ac

(d) The decision of the Board shall companied by a brief or supporting state

be final upon the expiration of 30 days ment.

from the date of the filing of the order, & 501.4 Transmittal of record.

unless the Board shall in its order fix & The Board shall serve upon the Direc different period of time or reconsiderator a copy of each application for re- tion by the Board is granted.

$ 501.7 Petition for reconsideration. specific materials desired to be in(a) Procedure for filing. A petition

spected. Any request will be denied as for reconsideration of a decision of the

to any papers or documents which the

Board determines are confidential, inBoard may be filed with the Board within

cluding, but without limitation, papers 30 days from the date of the order, or,

and documents containing information if another period is specified in the

affecting the security of the United order, then prior to the time when the

States or adversely affecting the interests order becomes final. The petition shall

of the United States or medical or other state the grounds relied upon, including

information which might result in damany matters claimed to have been er

age or harm to the appellant or any other roneously decided and shall specify the

person. alleged errors. The petition may be in letter form.

$ 501.9 Regulation of proceedings. (b) Answer; procedure for disposition

The proceedings shall be conducted of petitions. Upon the filing of a peti

under the supervision of the Chairman tion for reconsideration, each of the

or Acting Chairman, who shall regulate other parties to the proceeding may file

such matters as the granting of continuan answer thereto within such time as

ances, acceptance of briefs and other may be fixed by the Board. If recon

procedural matters. sideration should be granted, reargu-, ment upon reasonable notice may be al $ 501.10 Number of copies of pleadings lowed in the discretion of the Board. and related documents; service. After reconsideration of a case the Board

(a) Except as provided in paragraph shall either grant or deny the petition.

(b) of this section, any application, $ 501.8 Docket of proceedings; inspec pleading, petition, brief or other memotion of docket and records.

randum shall be filed in duplicate

(original and 1 copy) with the Board; (a) Maintenance of docket. A docket

the Board shall serve the copy upon the of all proceedings shall be maintained by

other party. the Board. Each proceeding shall be

(b) Instead of filing the duplicate of assigned a number in chronological order

any such document with the Board, the upon the date on which an application

party submitting it may serve the duplifor review is received. Each proceeding

cate or copy directly upon the Director shall be generally considered in the or

and make a notation to that effect upon der in which it is docketed, although for

the copy filed with the Board. good cause shown the Board may ad

(c) Any notice or order required unvance the order in which a particular

der this part to be given or served shall case is to be considered. Correspondence

be by certified or registered mail or by or further applications in connection

personal service. with any pending case shall refer to the docket number of that case.

$ 501.11 Appearances. (b) Inspection of docket and records.

(a) Representation. In any proceed. The docket of the Board shall be open to

ing before the Board, a party may appublic inspection. The Board shall

pear in person, or by counsel or any publish its decisions in such form as to

other duly authorized person, including be readily available for inspection, and

any accredited representative of an emshall allow the public inspection thereof

ployee organization. No person shall be at the permanent location of the Board.

recognized as representing an appelThe papers and documents included in

lant or intervenor unless there shall be the record of any proceeding shall be

filed with the Board a statement in writmade available to any party in interest

ing, signed by the party to be repreas provided in 29 CFR 2.6(b). The

sented, authorizing such representation. Board shall exercise the functions of the

Such representative when accepted shall Secretary of Labor prescribed in 29 CFR

continue to be recognized unless he 2.6(b). Such inspection shall be per

should abandon such capacity, withmitted at reasonable times during busi

draw, or the appellant or intervenor diness hours upon written request there

rects otherwise. for filed with the Board by an interested (b) Former members of the Board; party. Any request must set forth (1)

other employees of the Department of the interest of the applicant in the pro- Labor. A former member of the Board ceeding, and (2) a description of the shall not be allowed to participate as

843

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