DI / DE 2585B

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EDD Employment Development Department State of California Logo

Date: Blank Space
Claim ID: Blank Space
Claimant: Blank Space
Employer: Blank Space

Release of Information for Disputed Coverage Claim Referral

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We received your claim for State Disability Insurance (SDI) and determined that you are covered by your employer’s short-term disability plan. For reasons of confidentiality, we need your signed authorization to send the medical portion of your claim to your employer for consideration of payment.
Please complete and return this form to our office within 10 days.
Voluntary Plan Analyst Voluntary Plan Group, MIC 29VP PO Box 826880 Sacramento, CA 94280-0001
 
I,
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, hereby authorize the Employment Development Department (EDD), Disability Insurance (DI) program to release any or all medical information in my file to
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for the purpose of processing my claim for disability insurance (DI). This authorization includes the release of information about drug and alcohol abuse treatment.
This authorization is valid from the date of my signature, and I may revoke it at any time. In the event of revocation, any action that had already been taken in reliance on this authorization shall be agreed as conforming. In any case, this consent will expire upon the release of the above-stated information or the expiration of 30 days from the signature date below, whichever is later.
Signature:
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Date:
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DE 2585B Rev. 3 (9-21) (INTRANET)