DI / DE 8500B

SAMPLE, this page for reference only.

NONINDUSTRIAL DISABILITY INSURANCE
PO BOX 2168
STOCKTON CA 95201-2168
RETURN TO: 
NONINDUSTRIAL DISABILITY INSURANCE PO BOX 2168 STOCKTON CA 95201-2168
FIRSTNAME LASTNAME
‎1234 SAMPLE ST
ANY CITY CA 99999-9999
 
SSA NUMBER:
‎XXX-XX-0000
UNIT NUMBER:
999
MAILING DATE:
MM/DD/YY
CLAIM EFFECTIVE DATE:
MM/DD/YY
Information in your Non-industrial Disability Insurance (NDI) claim indicates that you were able or will be able to return to work on MM/DD/YY.
  • If you are still disabled: contact your doctor on or about the above date to have him/her complete the physician's supplementary certificate and return it to our office.
  • If you become disabled again: file a new Non-industrial Disability Insurance (NDI) claim form (DE8501).
This determination is final unless you file an appeal within 30 days from the above date, or submit the physician's supplementary certificate.

PHYSICIAN'S SUPPLEMENTARY CERTIFICATE

  1. Are you still treating the patient? Blank Line Last treatment dateBlank Line
  2. What present condition continues to make the patient disabled?
    1. ICD Code (required): Blank Line
    2. Diagnosis: Blank Line
  3. Date patient recovered, or will recover sufficiently (even if under treatment) to be able to perform his/her regular and customary work:
    1. Blank Line Please enter a specific or estimated recovery date.
  4. Would disclosure of this information to your patient be medically or psychologically detrimental to the patient?   Yes Blank line No Blank line

I hereby certify that the above statements in my opinion truly describe the claimant's condition and the estimated duration thereof.

Doctor's Signature
Blank line
Date Signed
Blank line
Phone Number
Blank line
State License Number
Blank line

State of California/Employment Development Department (EDD)

DE 8500B Rev. 3 (10-21) (INTRANET)