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SSA-1372A (F)--Statement to U.S. Social Security Administration by School Outside the United States About Student's Attendance. (For use in connection with a request for payment of child's insurance benefits for a child who is age 18 through 21 and a full-time student outside the United States.) SSA-1384-Student's Statement of Intent To Continue Schooling. (For use by a student beneficiary in determining eligibility for continuing child's insurance benefits during a period of nonattendance in school of not more than 4 calendar months' duration.) SSA-1442-Statement by Divorced Woman

Regarding Contributions and Support From Her Former Husband. SSA-1724-Claim for Amounts Due in the Case of a Deceased Beneficiary. (For use in requesting amounts payable under title II to a deceased beneficiary.) SSA-7156-Farm Self-Employment Questionnaire. (For use in connection with claims for benefits based on farm income to determine whether the income is covered under the Social Security Act.) SSA-7160-Employment Relationship Questionnaire. (For use by an individual and the alleged employer to determine the individual's employment status.) SSA-7163-Questionnaire About Employment or Self-Employment Outside United States. (To be completed by or on behalf of a beneficiary who is, was, or will be employed or self-employed outside the United States.) OAC-7203-Sick Pay and Plan or System Questionnaire. (To be completed by an employer for the purpose of determining the nature of special payments to an employee.)

[32 F.R. 18030, Dec. 16, 1967, as amended at 33 F.R. 11280, Aug. 8, 1968]

§ 422.510 Applications and related forms used in the health insurance for the aged program.

(a) Application forms. The following forms are prescribed for use in applying for entitlement to benefits under the health insurance for the aged program: SSA-18-Application for Hospital Insurance

Entitlement. (For use by individuals who are not entitled to retirement benefits under title II of the Social Security Act or under the Railroad Retirement Act. This form may also be used for enrollment in the supplementary medical insurance benefits plan.) SSA-40-Application for Enrollment in the

Supplementary Medical Insurance Program. (This form is mailed directly to beneficiaries at the beginning of their initial enrollment period.)

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ance. (For general use in requesting medical insurance protection.) SSA-40C-Application for Enrollment. (This form is mailed to beneficiaries as a followup on Form SSA-40 (Application for Enrollment in the Supplementary Medical Insurance Program).) SSA-40F-Application for Medical Insurance. (For use by beneficiaries residing outside the United States.)

An individual who upon attainment of age 65 is entitled to a monthly benefit based on application OA-C1, SSA-2, OA-C7, OA-C10, SSA-10A, OA-C13, or SSA-14 is automatically entitled to hospital insurance protection. (For conditions of entitlement to hospital insurance benefits see § 405.102 of this chapter.) For medical insurance protection, an applicant must request supplementary medical insurance coverage (see Forms SSA-40, SSA-40A, SSA-40B, SSA-40C, and SSA-40F under § 422.510 (a)). (For conditions of entitlement to supplementary medical insurance benefits see § 405.202 et seq. of this chapter.)

(b) Related forms. The following are the prescribed forms for use in requesting payment for services under the hos pital insurance benefits program and the supplementary medical insurance benefits program:

SSA-1453-Inpatient Hospital Admission and Billing. (To be completed by hospital for payment of hospital expenses for treatconfined of patient in the

ment hospital.) SSA-1478-Extended Care Admission and Billing. (To be completed by an extended care facility for payment of posthospital services.) SSA-1483-Outpatient Hospital Billing. (To be completed by hospital for payment of hospital expenses for treatment of patient who is not confined in the hospital.)

SSA-1484-Explanation of Accommodation Furnished. (To be completed by the hospital to explain accommodation of a patient in other than a semi-private (2to 4-bed) room.) SSA-1485-Inpatient Psychiatric or Tuberculosis Hospital Admission and Billing SSA-1486-Inpatient Admission and Bill ing-Christian Science Sanatorium (To be completed by Christian Science Sanstoriums for payment for treatment of patients confined in the sanatorium.) SSA-1487-Home Health Agency Report and Billing. (For use by an organization providing home health services.)

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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 Services by Physicians. (For use by hospitals for payment for services provided by hospital-based physicians.) SSA-1556—Prepayment Plan for Group Medical Practices Dealing Through a Carrier. (For use by organizations (which have been determined to be Group Practice Prepayment Plans for Medicare purposes) for reimbursement for medical services provided to beneficiaries.) SSA-1660-Statement of Person Requesting

Supplementary Medical Insurance Payment 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 insurance benefits or supplementary medical insurance benefits or both.)

[32 F.R. 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 Application. (For use by an individual to cancel his application.) OA-C561-Request for Reconsideration. (For who disagrees use by an individual 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 attorney authorized by a claimant to act for him in a claim or related matter.)

HA-512.1-Notice by Attorney of Appointment 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 Examiner'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 Identification Number.

SS-4A-Agricultural Employer's Application. (For use by employers of agricultural workers to request an employer identification number under the FICA.) SS-5-Application for Social Security Number (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 Household Employee. (For use by employers of household workers to request information from the District Director of Internal Revenue regarding filing employee tax reports.)

OA-702-Account Number Card. OA-702.1-Duplicate Account Number Card. 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. (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 provided under titles II and XVIII.) 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 SelfEmployment Coverage Fees Received by Certain Public Officers and Employees of a State or a Political Subdivision Thereof.

OAAN-5028-Temporary

Card.

Account Number

OAAN-7003-Request for Change in Social Security Records. (For use by an individual to change information given on original application for an account number.) OAR-7004 Request for Statement of Earnings. (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 discrepancy 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 SS-4 (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 modification 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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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; 3 CFR 1943-48 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.

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(a) "Act" means the Federal Employees' Compensation Act and any statutory extension or application thereof.

(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.

(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 rules; 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

Appeals Board, U.S. Department of Labor, Washington 25, D.C.

(c) Form of application; contents. An application for review should be filed with the Board upon Form AB-1 (Application for Review). Any application made without the use of the form shall contain the following information: The full name and address of the applicant, the name of the injured or deceased employee, the employing establishment, the case file number assigned to the case by the Bureau, a description of the particular injury involved, the date of the injury, the place of injury, and the date of the decision being appealed. If the applicant is being represented by another person in the proceeding, the name and address of such representative should be stated. Each application shall include a succinct statement indicating the contentions of the applicant and describing with particularity any findings of fact, conclusions of law, or exercise of (or failure to exercise) discretion complained of. Any application containing incomplete information shall be returned to the applicant with a description of the additional information needed and a reasonable opportunity for furnishing any such information shall be allowed.

(d) Time for filing. (1) Except as provided in subparagraph (2) of this paragraph, any application for review by a person residing within the United States or Canada must be filed within 90 days from the date of issuance of the final decision of the Director, and any application for review by a person residing outside the United States or Canada must be filed within 180 days from the date of issuance.

(2) For good cause shown, the Board may in its discretion waive a failure to file an application within the time limitations provided in subparagraph (1) of this paragraph, but for no longer than one year from the date of issuance of the final decision of the Director.

(3) The date of filing of an application for review shall be the date upon which the application is received by the Board.

(e) Briefs and supporting statements. Any application for review may be accompanied by a brief or supporting statement.

§ 501.4 Transmittal of record.

The Board shall serve upon the Director a copy of each application for re

view and any brief or supporting statement accompanying it. Within 30 days from the date of such service, the Director shall transmit to the Board the record of the proceeding to which the application refers and such statement in support of his decision or other pleading as he may consider necessary, but on application of the Director, the Board may in its discretion extend such time. § 501.5 Oral argument.

(a) Notice. Whenever any party requests an opportunity to present oral argument the Board shall schedule the case for argument. Each party shall be notified at least ten days before the date of argument. The notice shall state the issues to be heard, as determined by the Board.

(b) Time allowed. Generally not more than 1 hour shall be allowed for oral argument by any party although in appropriate cases the Board may in its discretion extend or shorten the time allowed.

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(a) The decision of the Board shall contain a written opinion setting forth the reasons for the action taken and an appropriate order. The decision may consist of affirmance, reversal, remand for further development of the evidence, or other appropriate action. A copy of the decision shall be sent by the Board to all parties in interest. The case record shall be returned to the Director with a copy of the decision.

(b) A decision of not less than two members shall be the decision of the Board.

(c) The decision of the Board shall be final as to the subject matter appealed and such decision shall not be subject to review, except by the Board.

(d) The decision of the Board shall be final upon the expiration of 30 days from the date of the filing of the order, unless the Board shall in its order fix a different period of time or reconsideration by the Board is granted.

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