Notice of Incomplete Disability Insurance Claim Form Returned to Medical Provider

Office Number:

Blank Line

MEDICAL PROVIDER:

Blank Space

Please return promptly and include this notice so your patient's claim for Disability Insurance (DI) benefits may be processed.

The enclosed Doctor's Certificate is being returned to you for the reason(s) checked below:

1.The "Claim Statement of Employee" lacks an address. We have been unable to contact your patient. Please furnish patient's address.
2. Please complete the "Doctor's Certificate" items checked in red.
3. Please provide your original signature.

All communications regarding this DI claim must include the claimant's Social Security number and be sent to the address shown on the enclosed, pre-addressed, reply envelope.

CLAIMANT:

Your claim or continued claim for DI benefits has been returned to your medical provider as indicated above. No determination can be made as to your eligibility for benefits until the claim form is returned to our office.

DE 2532 Rev. 5 (10-21) (INTRANET)

Your session has timed out.

Click here to access the application.

DI / DE 2532

Notice of Incomplete Disability Insurance Claim Form Returned to Medical Provider