DI / DE 2517-76

SAMPLE, this page for reference only.

Disability Insurance
PO Box
City CA ZIP Code

Notice of Determination – Certification Outside of Scope

 
Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY
Your claim for Disability Insurance (DI) has been disallowed beginning on MM/DD/YY until you are found eligible because of the reason below.
The individual who signed the medical portion of your claim is certifying to a medical condition outside their scope of practice. For Disability Insurance (DI) certification purposes, the activities permitted to be practiced by a nurse midwife, licensed midwife, or nurse practitioner are limited only to the treatment for conditions from a normal pregnancy, childbirth, or postpartum.
Basis: California Unemployment Insurance Code (CUIC) of Regulations, section 2708.
This determination is final unless you send a written appeal within 30 days from the mailing date listed above. You can appeal this decision by completing the enclosed Appeal Form or writing a detailed statement explaining why you believe the determination is incorrect. Include your Social Security number on your appeal and send it to the address above.

DE 2517-76 Rev. 3 (12-23) Notice of Determination (INTRANET)