DI / DE 2514-54

SAMPLE, this page for reference only

EDD - PAID FAMILY LEAVE
PO BOX 997017
SACRAMENTO CA 95899-7017
SAMPLE CLIENT
‎1234 ANY STREET
ANY CITY
 

Notice of Denied Paid Family Leave Benefits ‑ Medical Professional Acting Outside Scope of Practice

Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY

We are unable to pay you Paid Family Leave (PFL) benefits for MM/DD/YY through when eligible because:

The physician/practitioner who completed the physician/practitioner certification portion of your claim is not licensed to diagnose or treat the illness or injury shown in the certification.

If an appropriately licensed physician/practitioner completes a physician/practitioner certification and states that the care recipient needs your care, you may become eligible for benefits.

Basis:
California Unemployment Insurance Code (CUIC), section 2708.

This determination is final unless you send a written appeal within thirty days from the mailing date above. You may appeal by completing the enclosed Appeal Form or separately writing a detailed statement of why you believe the determination is in error. Please include your Social Security number on your appeal and send it to the EDD office shown above.

Notice of Determination

DE 2514-54 Rev. 2 (03-18) (INTRANET)