DENIAL OF VOCATIONAL REHABILITATION SERVICES Based on a review of your file, you are not eligible for vocational rehabilitation services at this time. Our decision is based on a determination that you are: Not Medically Eligible - See attached Physician's Report of Disability Status or other supporting documentation. Not Vocationally Feasible because: Our action involved only vocational rehabilitation. It does not affect your right to other workers' compensation benefits. You have the right to disagree with our decision. If you disagree, within fifteen days after receiving this letter, your or your representative must complete the two forms enclosed and return them to the Rehabilitation Unit office closest to you. The addresses and phone numbers of the Rehabilitation Unit of the Division of Workers' Compensation are on the back of the Case Initiation Document (Form No. RU-101). Under certain conditions you may have the right to reopen your case. Please refer to the enclosed pamphlet for additional information. You have 5 years from the date of injury to make this request. Please call me if you have questions. If you need more information, you may contact the California Division of Workers' Compensation by calling 1-800-736-7401, or you may consult an attorney. Attachments: cc: Request for Dispute Resolution Case Initiation Document Pamphlet Name: Signature: Phone #: MANDATORY FORMAT NOTICE OF NON-ELIGIBILITY STATE OF CALIFORNIA DWC FORM RU 500-Y (12/90) 2002 © American LegalNet, Inc.