HA-55 Objecton to Appearance by Video Teleconferencing

Form Approved
OMB 0960-0671

Social Security Administration

OBJECTION TO APPEARING BY VIDEO TELECONFERENCING
Name:
Social Security Number:
Wage Earner:
Hearing Office:

[ ]
Added
Checkbox

I do not want to appear at my hearing by video teleconference. Please schedule my
hearing so that I may appear in person.
Please return this form only if you object to a hearing by video teleconference.

Additional Comments:________________________________________________________________________________________

Signature:

Form HA-55 (12-2014)

Date:

Area Code and Telephone Number:

Revised
sentence

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(b)(1), 205(d) and 1631(c) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to acknowledge you are opting-out of an appearance
via video teleconferencing.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination regarding
benefits eligibility. However, we may use the information for the administration of our programs including
sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under
contract with us).
A complete list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notice 60-0089, entitled Claims Folder System. Additional information
about this and other system of records notices and our programs are available online at
www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or local
government agencies. We use the information from these programs to establish or verify a person’s
eligibility for federally funded or administered benefit programs and for repayment of incorrect
payments or delinquent debts under these programs.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44
U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need
to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 5 minutes to read the instructions, gather the facts, and
answer the questions. You may send comments on our time estimate above to: SSA, 6401 Security
Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.

Form HA-55 (12-2014)