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Question	Answer
Form Name	De2501Fc Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	form care edd, d edd my, 2501fc, edd 2501 pdf

Form Preview Example

Claim for Paid Family Leave (PFL) Care Benefits

Enter your receipt number here.

PART C – INSTRUCTIONS FOR PFL CARE CLAIMS

The care recipient (the person for whom you are providing care) must do the following: Complete and sign “Part C – Statement of Care Recipient.” If the care recipient is physically or mentally unable to sign, call PFL at 1-877-238-4373 for instructions.

The care recipient’s physician/practitioner must complete “Part D – Physician/ Practitioner’s Certification” either electronically in SDI Online, or by completing and signing page 3 of Claim for Paid Family Leave (PFL) Care Benefits (DE 2501FC). If the care recipient is under the care of an accredited religious practitioner, call PFL at 1-877-238-4373 for the proper form Practitioner’s Certification for Paid Family Leave Benefits (DE 2502F).

The easiest way to have your claim processed is to submit the completed forms electronically in SDI Online as an attachment. If submitting by mail, send to the following address: Paid Family Leave, PO Box 997017, Sacramento, CA 95899-7017. If submitting electronically, return to the Homepage of your SDI Online account. Select New Claim from the Menu, and select Submit Electronic Paid Family Leave Care Attachment.

PART C – STATEMENT OF		(MAY BE COMPLETED BY CLAIMANT IF CARE RECIPIENT IS MENTALLY OR PHYSICALLY UNABLE TO DO SO.
	CARE RECIPIENT	MUST BE SIGNED BY CARE RECIPIENT OR CARE RECIPIENT’S AUTHORIZED REPRESENTATIVE.)
C1.	CARE PROVIDER SSN	C2. RECIPIENT’S DATE OF BIRTH		C3. RECIPIENT’S PHONE NUMBER		C4. RECIPIENT’S GENDER
						MALE	FEMALE

C5.	LEGAL NAME OF CARE RECIPIENT (FIRST, MIDDLE INITIAL, LAST)

C6.	CARE RECIPIENT’S RESIDENCE ADDRESS
CITY		STATE/PROV.	ZIP OR POSTAL CODE		COUNTRY (IF NOT U.S.A.)

C7. CONFIRMATION OF MEDICAL DISCLOSURE AUTHORIZATION. I authorize my physician/practitioner to disclose my current personal-health information to my care provider and to the California Employment Development Department (EDD). I further understand that copies of my signature below are as valid as the original.

Care Recipient’s Signature (DO NOT PRINT)

_______________________________________________________________________________	Date Signed
C8. Authorized Representative signing on behalf of care recipient must complete the following: I,	, represent the care recipient in
this matter as authorized by parental right power of attorney (attach copy) court order (attach copy) (For spouse or domestic partner, contact EDD).
Authorized Representative’s Signature (DO NOT PRINT)
_______________________________________________________________________________	Date Signed

E 2501FC Rev. 5 (12-20) (INTERNET)

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Enter your receipt number here.

LEFT BLANK INTENTIONALLY

E 2501FC Rev. 5 (12-20) (INTERNET)

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Medical certifications must be completed by a licensed physician or practitioner authorized to certify to a patient’s disability/serious health condition pursuant to California Unemployment Insurance Code Section 2708.

Enter your receipt number here.

PART D – PHYSICIAN/PRACTITIONER’S CERTIFICATION

D1.	PFL CLAIMANT’S (CARE
	PROVIDER’S) SOCIAL
	SECURITY NUMBER		D2. PFL CLAIMANT’S NAME (FIRST, MIDDLE INITIAL, LAST)

D3.	PATIENT’S DATE OF BIRTH		D4. DOES YOUR PATIENT REQUIRE CARE BY THE CARE PROVIDER?
			YES	NO (SKIP TO D15)

D5.	PATIENT’S NAME (FIRST, MIDDLE INITIAL, LAST)

D6.	DIAGNOSIS OR, IF NOT YET DETERMINED, A DETAILED STATEMENT OF SYMPTOMS

D7.	PRIMARY ICD CODE		D8. SECONDARY ICD CODES					D9. DATE PATIENT’S CONDITION COMMENCED

			D11. DATE YOU ESTIMATE PATIENT WILL NO LONGER REQUIRE CARE BY
D10.	FIRST DATE CARE NEEDED		THE CARE PROVIDER					D12. DATE YOU EXPECT RECOVERY
					PERMANENT CARE REQUIRED			NEVER

D13.	APPROXIMATELY HOW MANY TOTAL HOURS PER DAY WILL PATIENT REQUIRE CARE BY A CARE PROVIDER?
HOURS		COMMENTS

D14.	WOULD DISCLOSURE OF THE MEDICAL INFORMATION ON THIS					D15. PHYSICIAN/		D16. STATE OR COUNTRY (IF NOT U.S.A.) IN WHICH
	CERTIFICATE BE MEDICALLY OR PSYCHOLOGICALLY DETRIMENTAL TO					PRACTITIONER’S		PHYSICIAN/PRACTITIONER IS LICENSED TO
	YOUR PATIENT?					LICENSE NUMBER		PRACTICE
	YES	NO

D17.	PHYSICIAN/PRACTITIONER’S NAME (FIRST, MIDDLE INITIAL, LAST)

D18.	PHYSICIAN/PRACTITIONER’S ADDRESS (POST OFFICE BOX IS NOT ACCEPTABLE AS THE SOLE ADDRESS)
CITY			STATE/PROV.	ZIP OR POSTAL CODE			COUNTRY (IF NOT U.S.A.)

D19.	TYPE OF PHYSICIAN/PRACTITIONER					D20. SPECIALTY (IF ANY)

D21.	Physician/Practitioner’s Certification:
	I certify under penalty of perjury that this patient has a serious health condition and requires a care provider. I have performed a physical examination and/or treated
	the patient. I am authorized to certify a patient disability or serious health condition pursuant to California Unemployment Insurance Code section 2708.
	Original Signature of physician/practitioner –
	RUBBER STAMP IS NOT ACCEPTABLE
	__________________________________________________________________________
	PHYSICIAN/PRACTITIONER’S PHONE NUMBER					DATE SIGNED

Under sections 2116 and 2122 of the California Unemployment Insurance Code, it is a violation for any individual who, with intent to defraud, falsely certifies the medical condition of any person in order to obtain disability insurance benefits, whether for the maker or for any other person, and is punishable by imprisonment and/or a fine not exceeding $20,000. Sections 1143 and 3305 require additional administrative penalties.

E 2501FC Rev. 5 (12-20) (INTERNET)

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FEDERAL PRIVACY ACT. The EDD requires disclosure of Social Security numbers on a mandatory basis to comply with California Unemployment Insurance Code, sections 1253 and 2627; with California Code of Regulations, Title 22, sections 1085, 1088, and 1326; with Code of Federal Regulations, Title 20, Part 604; and with U.S. Code, Title 8, sections 1621, 1641, and 1642.

INFORMATION COLLECTION AND ACCESS. State law requires the following information to be provided when collecting information from individuals:

Agency Name:

Employment Development Department (EDD)

Title of Official Responsible for Information Maintenance:

Manager, EDD Paid Family Leave Office

Local Contact Person:

Manager, EDD Paid Family Leave Office

Address and Telephone Number:

The address and phone number of Paid Family Leave will appear on the Notice of Computation (DE 429D), issued at the time your benefit determination is made.

Maintenance of the Information is authorized by:

California Unemployment Insurance Code, sections 2601 through 3306.

California Code of Regulations, Title 22, sections 2706-1, 2706-3, 2708-1, and 2710-1.

Consequences of not providing all or any part of the requested information:

•Failure to supply any or all information may cause delay in issuing benefit payments or may cause you to be denied benefits to which you are entitled.

•If you willfully make a false statement, representation, or knowingly withhold a material fact to obtain or increase any benefit or payment, the EDD will disqualify you from receiving benefits and/or services and may initiate criminal prosecution against you.

Principal purpose(s) for which the information is to be used:

•To determine eligibility for Paid Family Leave benefits.

•To be summarized and published in statistical form for the use and information of government agencies and the public. (Neither your name and identification nor the name and identification of the care recipient will appear in publications.)

•To be used to locate persons who are being sought for failure to provide child or spousal support.

•To be used by other governmental agencies to determine eligibility for public social services under the provisions of California Welfare and Institutions Code, Division 9.

•To be used by the EDD to carry out its responsibilities under the California Unemployment Insurance Code.

•To be exchanged pursuant to California Unemployment Insurance Code, section 322, and California Civil Code, section 1798.24, with other governmental departments and agencies, both federal and state, which are concerned with any of the following:

(1)Administration of an unemployment insurance program.

(2)Collection of taxes which may be used to finance unemployment insurance or disability insurance.

(3)Relief of unemployed or destitute individuals.

(4)Investigation of labor law violations or allegations of unlawful employment discrimination.

(5)The hearing of workers’ compensation appeals.

(6)Whenever necessary to permit a state agency to carry out its mandated responsibilities where the use to which the information will be put is compatible with the purpose for which it was gathered.

(7)When mandated by state or federal law. Disclosures under California Unemployment Insurance Code, section 322, will be made only in those instances in which it furthers the administration of the programs mandated by that Code.

•Pursuant to California Unemployment Insurance Code, sections 1095 and 2714, information may be revealed to the extent necessary for the administration of public social services or to the Director of Social Services or his/her representatives.

•Information shall be disclosed to authorized agencies in accordance with California Unemployment Insurance Code, sections 1095 and 2714.

E 2501FC Rev. 5 (12-20) (INTERNET)

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How to Edit De2501Fc Form Online for Free

The purpose supporting our PDF editor was to make certain it is as straightforward as possible. You'll find the complete process of completing edd 2501 pdf rather simple when you adhere to all of these steps.

Step 1: Select the button "Get Form Here" on the site and press it.

Step 2: Now, you're on the document editing page. You may add content, edit present details, highlight specific words or phrases, put crosses or checks, add images, sign the document, erase unnecessary fields, etc.

The PDF form you are going to create will consist of the next parts:

Enter the required details in PART, C, STATEMENT, OF, CARE, RECIPIENT CC, ARE, PROVIDERS, SN C, RECIPIENTS, DATEOFBIRTH C, RECIPIENTS, PHONE, NUMBER C, RECIPIENTS, GENDER MALE, FEMALE, CC, ARE, RECIPIENTS, RESIDENCE, ADDRESS STATE, PRO, V ZIP, OR, POSTAL, CODE COUNTRY, IF, NOT, USA Care, Recipients, Signature, DO, NOT, PRINT Date, Signed represent, the, care, recipient, in and this, matter, as, authorized, by section.

You should identify the significant details from the LEFT, BLANK, INTENTIONALLY and Enter, your, receipt, number, here field.

The Enter, your, receipt, number, here PROVIDERS, SOCIAL, SECURITY, NUMBER D, PATIENTS, DATEOFBIRTH YES, NO, SKIP, TOD D, PATIENTS, NAME, FIRST, MIDDLE, INITIAL, LAST D, PRIMARY, ICD, CODE D, SECONDARY, ICD, CODES D, DATE, PATIENTS, CONDITION, COMMENCED D, FIRST, DATE, CARE, NEEDED THE, CARE, PROVIDER D, DATE, YOU, EXPECT, RECOVERY PERMANENT, CARE, REQUIRED NEVER, and HOURS box can be used to specify the rights and obligations of both sides.

2501 fc form Enteryourreceiptnumberhere, PROVIDERSSOCIALSECURITYNUMBER, DPATIENTSDATEOFBIRTH, YES, NOSKIPTOD, DPATIENTSNAMEFIRSTMIDDLEINITIALLAST, DPRIMARYICDCODE, DSECONDARYICDCODES, DDATEPATIENTSCONDITIONCOMMENCED, DFIRSTDATECARENEEDED, THECAREPROVIDER, DDATEYOUEXPECTRECOVERY, PERMANENTCAREREQUIRED, NEVER, and HOURS blanks to complete

Review the fields PRACTITIONERS, LICENSE, NUMBER YES, CITY, STATE, PRO, V ZIP, OR, POSTAL, CODE COUNTRY, IF, NOT, USA D, TYPE, OF, PHYSICIAN, PRACTITIONER D, SPECIALTY, IF, ANY PHYSICIAN, PRACTITIONERS, PHONE, NUMBER and DATE, SIGNED and next fill them in.

Step 3: Hit the "Done" button. Next, it is possible to transfer your PDF document - upload it to your device or forward it by using email.

Step 4: Make sure you stay clear of possible future misunderstandings by generating as much as 2 copies of your document.

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