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.

G-DI_23580.005A-1

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G-DI 23580.005A-2

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G-DI_23580.005A-3

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B. SPANISH NOTICE

G-DI_23580.005B-1

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G-DI_23580.005B-2

Printer Friendly Version

G-DI_23580.005B-3

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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: 01/27/2009
Rev:09/21/2004