TN 1 (09-04)

DI 23580.005 Exhibit 3 – Disability Redesign Prototype DDS Postentitlement Notice - Unfavorable Determination

A. ENGLISH NOTICE

NOTE: Page 1 of the notice, third paragraph, second fill-in, select “A” if the claimant is not determined to have ALS; select “B” if the claimant is determined to have ALS after expiration of the 24-month Medicare waiting period established by the original (non-ALS) onset.

B. SPANISH NOTICE


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0423580005
DI 23580.005 - Exhibit 3 – Disability Redesign Prototype DDS Postentitlement Notice - Unfavorable Determination - 09/21/2004
Batch run: 04/14/2014
Rev:09/21/2004