Claim For Disability Insurance (Di) Benefits (De 2501)

DE 2501 Rev. 79 (10-16) (INTERNET) Page 1 of 7

250110161

Claim for Disability Insurance (DI) Beneﬁts

Health Insurance Portability and Accountability Act (HIPAA) Authorization

(Person/Organization providing the information) to furnish and disclose all my health

information and to allow inspection of and provide copies of any medical, vocational

rehabilitation, and billing records concerning my disability for which this claim is ﬁled

that are within their knowledge to the following employees of the California Employment

Development Department (EDD): Disability Insurance Branch examiners, their direct

supervisors/managers and any other EDD employee who may have a need to access

this information in order to process my claim and/or determine eligibility for State

Disability Insurance beneﬁts.

I understand that EDD is not a health plan or health care provider, so the information

released to EDD may no longer be protected by federal privacy regulations.

(45 CFR Section 164.508(c)(2)(iii)). EDD may disclose information as authorized by

the California Unemployment Insurance Code.

I agree that photocopies of this authorization shall be as valid as the original.

I understand I have the right to revoke this authorization by sending written notiﬁcation

stopping this authorization to EDD, DI Branch MIC 29, PO Box 826880, Sacramento,

CA 94280. The authorization will stop on the date my request is received. I understand

that the consequences for my revoking this authorization may result in denial of further

State Disability Insurance beneﬁts.

I understand that, unless revoked by me in writing, this authorization is valid for ﬁfteen

years from the date received by EDD or the effective date of the claim, whichever is

later. I understand that I may not revoke this authorization to avoid prosecution or to

prevent EDD‘s recovery of monies to which it is legally entitled.

I understand that I am signing this authorization voluntarily and that payment or

eligibility for my beneﬁts will be affected if I do not sign this authorization. The

consequences for my refusal to sign this authorization may result in an incomplete

claim form that cannot be processed for payment of State Disability Insurance beneﬁts.

I understand I have the right to receive a copy of this authorization.

I authorize

CU

Claimant Signature (Do Not Print)

Date Signed

Claimant Social Security Number

Claimant Name

(First) (MI) (Last)

M

M D D Y Y Y Y

SAMPLE

DE 2501 Rev. 79 (10-16) (INTERNET) Page 2 of 7

250110162

A1. YOUR SOCIAL SECURITY

NUMBER

A5. IF YOU EVER USED OTHER SOCIAL SECURITY NUMBERS,

ENTER THOSE NUMBERS BELOW

A12. LANGUAGE YOU PREFER TO USE

A13. YOUR MAILING ADDRESS, PO BOX OR NUMBER/STREET/APARTMENT, SUITE, SPACE#, OR PMB#

(PRIVATE MAIL BOX)

A15. YOUR LAST OR CURRENT EMPLOYER - IF YOUR LAST OR CURRENT EMPLOYMENT WAS SELF-EMPLOYMENT, ENTER “SELF” AND FILL-IN THIS OPTION.

NAME OF YOUR EMPLOYER [STATE GOVERNMENT EMPLOYEES: PROVIDE THE AGENCY NAME (FOR EXAMPLE: CALTRANS)]

CITY STATE ZIP OR POSTAL CODE COUNTRY (IF NOT U.S.A.)

NUMBER/STREET/SUITE# (STATE GOVERNMENT EMPLOYEES: PLEASE PROVIDE THE ADDRESS OF YOUR PERSONNEL OFFICE)

CITY STATE ZIP OR POSTAL CODE COUNTRY

(IF NOT U.S.A.)

A8. YOUR LEGAL NAME (FIRST) (MI) (LAST) SUFFIX

SUFFIX

ENGLISH SPANISH CANTONESE VIETNAMESE ARMENIAN PUNJABI TAGALOG OTHER

A10. YOUR HOME AREA CODE AND TELEPHONE NUMBER

A11. YOUR CELL AREA CODE AND TELEPHONE NUMBER

A2. IF YOU HAVE PREVIOUSLY BEEN ASSIGNED AN EDD

CUSTOMER ACCOUNT NUMBER, ENTER THAT NUMBER HERE

A4. GENDER

MALE FEMALE

A3. CALIFORNIA DRIVER

LICENSE OR ID NUMBER

A7. YOUR DATE OF BIRTH

A6. STATE GOVERNMENT EMPLOYEE

(IF “YES” INDICATE BARGAINING UNIT#)

YES

M

M D D Y Y Y Y

NO UNIT#

PART A - CLAIMANT’S STATEMENT

Your disability claim can also be ﬁled online at www.edd.ca.gov/

PLEASE PRINT WITH BLACK INK.

SELF

A14. YOUR RESIDENCE ADDRESS, REQUIRED IF DIFFERENT FROM YOUR MAILING ADDRESS

NUMBER/STREET/APARTMENT OR SPACE#

A9. OTHER NAMES, IF ANY, UNDER WHICH YOU HAVE WORKED

CITY STATE ZIP OR POSTAL CODE COUNTRY (IF NOT U.S.A.)

(FIRST) (MI) (LAST)

(FIRST)

(MI) (LAST)

A17. BEFORE YOUR DISABILITY BEGAN, WHAT

WAS THE LAST DAY YOU WORKED?

M

M D D Y Y Y Y

A18. WHEN DID YOUR DISABILITY BEGIN? A19. DATE YOU WANT YOUR CLAIM TO BEGIN IF DIFFERENT THAN THE DATE ENTERED IN A18

MM

MM DD DD YY YY YY YY

A21 A. IF YOU RECOVERED, ENTER DATE: A21 B. IF YOU RETURNED TO WORK,

ENTER DATE:

M

D

Y

A20. SINCE YOUR DISABILITY BEGAN, HAVE YOU WORKED OR

ARE YOU WORKING ANY FULL OR PARTIAL DAYS?

YES NO

A16. AT ANY TIME DURING YOUR DISABILITY, WERE YOU IN THE CUSTODY OF LAW ENFORCEMENT

VIOLATING A LAW OR ORDINANCE?

AUTHORITIES BECAUSE YOU WERE CONVICTED OF

YES NO

EMPLOYER’S TELEPHONE NUMBER

SAMPLE

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250110163

A34. WORKERS’ COMPENSATION INSURANCE COMPANY NAME AREA CODE AND TELEPHONE NUMBER EXTENSION (IF ANY)

NUMBER/STREET/SUITE#

CITY STATE ZIP CODE WORKERS’ COMPENSATION CLAIM NUMBER

A25. HOW WOULD YOU DESCRIBE OR CLASSIFY YOUR JOB?

Mostly sit; occasionally stand or walk; occasionally lift, carry, push, pull, or otherwise move objects that weigh 10 lbs. or less.

Mostly walk/stand; occasionally lift, carry, push, pull, or otherwise move objects that weigh up to 20 lbs.

Constantly lift, carry, push, pull, or otherwise move objects that weigh up to 10 lbs.; frequently up to 20 lbs.; occasionally up to 50 lbs.

Constantly lift, carry, push, pull, or otherwise move objects that weigh up to 20 lbs.; frequently up to 50 lbs.; occasionally up to 100 lbs.

Constantly lift, carry, push, pull, or otherwise move objects that weigh over 20 lbs.; frequently over 50 lbs.; occasionally over 100 lbs.

A33. DATE(S) OF INJURY SHOWN ON YOUR WORKERS’ COMPENSATION CLAIM

M

M M M

M

M M M

D

D D D

D

D D D

Y

Y Y Y

Y

Y Y Y

Y

Y Y Y

Y

Y Y Y

A26. IF YOUR EMPLOYER(S) CONTINUED OR WILL CONTINUE TO PAY YOU DURING YOUR DISABILITY, INDICATE

TYPE OF PAY:

SICK VACATION (PTO) ANNUAL

Paid Time Off

A27. MAY WE DISCLOSE BENEFIT PAYMENT

INFORMATION TO YOUR EMPLOYER(S)?

YES NO

OTHER (EXPLAIN)

A28. SECOND EMPLOYER NAME (IF YOU HAVE MORE THAN ONE EMPLOYER)

NUMBER/STREET/SUITE#

CITY STATE ZIP OR POSTAL CODE COUNTRY

(IF NOT U.S.A.)

BEFORE YOUR DISABILITY BEGAN, WHAT WAS THE LAST DAY YOU WORKED FOR THIS EMPLOYER? EMPLOYER’S TELEPHONE NUMBER

M

M D D Y Y Y Y

A30. IF YOU ARE A RESIDENT OF AN ALCOHOLIC RECOVERY HOME OR A DRUG-FREE RESIDENTIAL FACILITY, PROVIDE THE FOLLOWING:

NAME OF FACILITY

NUMBER/STREET/SUITE#

CITY STATE ZIP OR POSTAL CODE AREA CODE AND TELEPHONE NUMBER

A24. WHY DID YOU STOP WORKING? (SELECT ONLY ONE BOX)

LAYOFF UNPAID LEAVE OF ABSENCE VOLUNTARILY QUIT OR RETIRED TERMINATED OTHER REASON

ILLNESS, INJURY, OR PREGNANCY

A29. IF YOU HAVE MORE THAN 2 EMPLOYERS CHECK HERE.

PART A - CLAIMANT’S STATEMENT - CONTINUED

A22. PLEASE RE-ENTER YOUR SOCIAL SECURITY NUMBER

A31. HAVE YOU FILED OR DO YOU INTEND TO FILE FOR WORKERS’ COMPENSATION BENEFITS?

YES - COMPLETE ITEMS A32 THROUGH A38 NO - SKIP ITEMS A33 THROUGH A38

A32. WAS THIS DISABILITY CAUSED BY YOUR JOB?

YES NO

A23. WHAT IS YOUR REGULAR OR CUSTOMARY OCCUPATION?

SAMPLE

DE 2501 Rev. 79 (10-16) (INTERNET) Page 4 of 7

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ATTORNEY’S ADDRESS NUMBER/STREET/SUITE#

CITY STATE ZIP CODE BOARD/ADJ CASE NUMBER

PLEASE REVIEW, SIGN, AND DATE ITEM A39, AND IF APPLICABLE, ITEMS A40 AND A41

WORKERS’ COMPENSATION APPEALS

A38. YOUR ATTORNEY’S NAME (IF ANY) FOR YOUR WORKERS’ COMPENSATION CASE AREA CODE AND TELEPHONE NUMBER EXTENSION (IF ANY)

A36. WORKERS’ COMPENSATION ADJUSTER’S NAME AREA CODE AND TELEPHONE NUMBER EXTENSION (IF ANY)

A37. EMPLOYER’S NAME SHOWN ON YOUR WORKERS’ COMPENSATION CLAIM AREA CODE AND TELEPHONE NUMBER EXTENSION (IF ANY)

A40. IF YOUR SIGNATURE IS MADE BY MARK (X), CHECK THE BOX AND IT MUST BE ATTESTED BY TWO WITNESSES WITH THEIR ADDRESSES.

1st WITNESS SIGNATURE (PRINT AND SIGN)

2nd WITNESS SIGNATURE (PRINT AND SIGN)

NUMBER/STREET/APARTMENT OR SPACE#, PO BOX OR PRIVATE MAIL BOX ADDRESSES NOT ACCEPTABLE.

(FIRST) (MI) (LAST)

CITY STATE ZIP CODE

A39. Declaration and Signature. By my signature on this claim statement, I claim beneﬁts and certify that for the period covered by

this claim I was unemployed and disabled. I understand that willfully making a false statement or concealing a material fact in order to

obtain payment of beneﬁts is a violation of California law and that such violation is punishable by imprisonment or ﬁne or both. I declare

under penalty of perjury that the foregoing statement, including any accompanying statements, is to the best of my knowledge and

belief true, correct, and complete. By my signature on this claim statement, I authorize the California Department of Industrial Relations

and my employer to furnish and disclose to State Disability Insurance all facts concerning my disability, wages or earnings, and beneﬁt

payments that are within their knowledge. By my signature on this claim statement, I authorize release and use of information as stated

in the “Information Collection and Access” portion of this form (see Informational Instructions, page D). I agree that photocopies of this

authorization shall be as valid as the original, and I understand that authorizations contained in this claim statement are granted for a

period of ﬁfteen years from the date of my signature or the effective date of the claim, whichever is later.

CLAIMANT’S SIGNATURE (DO NOT PRINT) OR SIGNATURE MADE BY MARK (X)

DATE SIGNED

A41. CHECK THIS BOX IF YOU ARE THE PERSONAL REPRESENTATIVE SIGNING ON BEHALF OF CLAIMANT AND COMPLETE THE FOLLOWING:

THIS MATTER AS AUTHORIZED BY DECLARATION OF INDIVIDUAL CLAIMING DISABILITY INSURANCE BENEFITS DUE AN INCAPACITATED OR DECEASED

CLAIMANT, DE

2522 (SEE INSTRUCTION & INFORMATION A, UNDER HOW TO APPLY #4) POWER OF ATTORNEY (ATTACH COPY)

, REPRESENT THE CLAIMANT IN

M

D

Y

PERSONAL REPRESENTATIVE’S SIGNATURE (DO NOT PRINT)

DATE SIGNED

M

M D D Y Y Y Y

I,

PART A - CLAIMANT’S STATEMENT - CONTINUED

A35. PLEASE RE-ENTER YOUR SOCIAL SECURITY NUMBER

SAMPLE

DE 2501 Rev. 79 (10-16) (INTERNET) Page 5 of 7

250110165

B2. PATIENT’S FILE NUMBER

MAILING ADDRESS, PO BOX OR NUMBER/STREET/SUITE#

FACILITY ADDRESS, NUMBER/STREET/SUITE#

FACILITY NAME

(IF APPLICABLE)

B11. PHYSICIAN/PRACTITIONER’S ADDRESS

COUNTY HOSPITAL/GOVERNMENT FACILITY ADDRESS

B13. AT ANY TIME DURING YOUR ATTENDANCE FOR THIS MEDICAL PROBLEM, HAS THE PATIENT BEEN INCAPABLE OF PERFORMING HIS/HER REGULAR

OR CUSTOMARY WORK?

B5. PATIENT’S NAME (FIRST) (MI) (LAST)

(FIRST) (MI) (LAST) SUFFIX

B10. PHYSICIAN/PRACTITIONER’S NAME AS SHOWN ON LICENSE

B12. THIS PATIENT HAS BEEN UNDER MY CARE AND TREATMENT FOR THIS MEDICAL PROBLEM

AT INTERVALS OF:

DAILY WEEKLY MONTHLY AS NEEDED OTHER

FROM TO

B6. PHYSICIAN/PRACTITIONER’S LICENSE NUMBER

B7. STATE OR COUNTRY (IF NOT U.S.A.) THAT ISSUED LICENSE NUMBER ENTERED IN B6

STAT E COUNTRY

B3. IF YOU KNOW THE PATIENT’S ELECTRONIC RECEIPT NUMBER, ENTER IT HERE: B4. PATIENT’S DATE OF BIRTH

M

D

Y

Claim for Disability Insurance (DI) Beneﬁts -

Physician/Practitioner’s Certiﬁcate

PLEASE PRINT WITH BLACK INK.

B1. PATIENT’S SOCIAL SECURITY NUMBER

PART B - PHYSICIAN/PRACTITIONER’S CERTIFICATE

CITY STATE ZIP OR POSTAL CODE COUNTRY (IF NOT U.S.A.)

M

M D D Y Y Y Y

CHECK HERE TO INDICATE YOU ARE STILL TREATING THE PATIENT

YES - ENTER DATE DISABILITY BEGAN

WAS THE DISABILITY CAUSED BY AN ACCIDENT OR TRAUMA?

IF YES, INDICATE THE DATE THE ACCIDENT OR TRAUMA OCCURRED.

NO - SKIP TO B33

YES

R

NO

B15. IF PATIENT IS NOW PREGNANT OR HAS BEEN PREGNANT, PLEASE CHECK THE APPROPRIATE BOX AND ENTER THE FOLLOWING:

ESTIMATED DELIVERY DATE: DATE PREGNANCY ENDED:

M

D

Y

TYPE OF DELIVERY, IF PATIENT HAS DELIVERED: VAGINAL CESAREAN

M

M D D Y Y Y Y

B14. DATE YOU RELEASED OR ANTICIPATE RELEASING PATIENT TO RETURN TO HIS/HER REGULAR OR CUSTOMARY WORK

(“UNKNOWN”, “INDEFINITE”, ETC., NOT ACCEPTABLE.)

CHECK HERE TO INDICATE PATIENT’S DISABILITY IS PERMANENT AND YOU NEVER ANTICIPATE RELEASING PATIENT TO RETURN TO HIS/HER

REGULAR OR CUSTOMARY WORK

B8. PHYSICIAN/PRACTITIONER LICENSE TYPE B9. SPECIALTY (IF ANY)

SAMPLE

DE 2501 Rev. 79 (10-16) (INTERNET) Page 6 of 7

250110166

PART B - PHYSICIAN/PRACTITIONER’S CERTIFICATE - CONTINUED

B16. PLEASE RE-ENTER PATIENT’S SOCIAL SECURITY NUMBER

B22. TYPE OF TREATMENT/MEDICATION RENDERED TO PATIENT

B21. FINDINGS - STATE NATURE, SEVERITY, AND EXTENT OF THE INCAPACITATING DISEASE OR INJURY, INCLUDE ANY OTHER DISABLING CONDITIONS

B24. CHECK HERE IF PATIENT IS DECEASED, PLEASE PROVIDE DATE OF DEATH

M

M D D Y Y Y Y

B23. IF PATIENT WAS HOSPITALIZED, PROVIDE DATES OF ENTRY AND DISCHARGE

MM

MM DD DD YY YY YY YY

TO

CHECK HERE TO INDICATE THE PATIENT IS STILL HOSPITALIZED

B20. DIAGNOSIS (REQUIRED) - IF NO DIAGNOSIS HAS BEEN DETERMINED, ENTER A DETAILED STATEMENT OF SYMPTOMS

CITY COUNTY STATE

B18. IN CASE OF AN ABNORMAL PREGNANCY AND/OR DELIVERY, STATE THE COMPLICATION(S) CAUSING MATERNAL DISABILITY

B17. IF THE PATIENT HAS NOT DELIVERED AND YOU DO NOT ANTICIPATE RELEASING THE PATIENT TO RETURN TO REGULAR OR CUSTOMARY WORK PRIOR

TO THE ESTIMATED DELIVERY DATE, ENTER THE NUMBER OF DAYS THAT THE PATIENT WILL BE DISABLED POSTPARTUM, FOR EACH DELIVERY TYPE:

VAGINAL DELIVERY CESAREAN DELIVERY

B19. ICD DIAGNOSIS CODE(S) FOR DISABLING CONDITION THAT PREVENT THE PATIENT FROM

PERFORMING HIS/HER REGULAR OR CUSTOMARY WORK (REQUIRED)

PRIMARY

SECONDARY

ICD-9

ICD-10

EXAMPLE OF HOW TO

COMPLETE ICD CODES

ICD-9

ICD-10

.

3

G

2

0

0 1

.

..

.

(Check only one box)

SAMPLE

DE 2501 Rev. 79 (10-16) (INTERNET) Page 7 of 7

250110167

PART B - PHYSICIAN/PRACTITIONER’S CERTIFICATE - CONTINUED

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. SECTION 1143 REQUIRES ADDITIONAL ADMINISTRATIVE PENALTIES.

B33.

PHYSICIAN/PRACTITIONER’S ORIGINAL SIGNATURE - RUBBER STAMP

IS NOT ACCEPTABLE

M

M D D Y Y Y Y

AREA CODE/PHONE NUMBER DATE SIGNED

B31. DATE YOUR PATIENT BECAME A RESIDENT OF A DRUG OR ALCOHOL FACILITY (IF KNOWN)

B32. WOULD DISCLOSURE OF THE INFORMATION ON THIS FORM BE MEDICALLY OR PSYCHOLOGICALLY DETRIMENTAL TO YOUR PATIENT?

M

M D D Y Y Y Y

YES NO

B25. PLEASE RE-ENTER PATIENT’S SOCIAL SECURITY NUMBER

B30. ARE YOU COMPLETING THIS FORM FOR THE SOLE PURPOSE OF REFERRAL/RECOMMENDATION TO AN ALCOHOLIC RECOVERY HOME OR DRUG-FREE

RESIDENTIAL FACILITY AS INDICATED BY THE PATIENT IN QUESTION A30?

YES NO

B29. WAS THIS DISABLING CONDITION CAUSED AND/OR AGGRAVATED BY THE PATIENT’S REGULAR OR CUSTOMARY WORK? YES NO

PHYSICIAN/PRACTITIONER’S: I CERTIFY UNDER PENALTY OF PERJURY THAT THE PATIENT IS UNABLE TO PERFORM HIS/HER REGULAR OR

CUSTOMARY WORK BECAUSE OF THE LISTED DISABLING CONDITION(S). 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.

B28. ICD PROCEDURE CODE(S)

CPT CODE(S) (DO NOT INCLUDE MODIFIERS)

B27. DATE AND TYPE OF SURGERY/PROCEDURE MOST RECENTLY PERFORMED OR TO BE PERFORMED

WAS THE PATIENT UNABLE TO WORK IMMEDIATELY PRIOR TO THE SURGERY OR PROCEDURE?

IF YES, PLEASE PROVIDE THE FIRST DATE THE PATIENT WAS UNABLE TO WORK BEFORE THE SURGERY OR PROCEDURE

M

D

Y

. . . .

Y

YES NO

ICD-9 ICD-10

B26. WAS THE PATIENT SEEN PREVIOUSLY BY ANOTHER PHYSICIAN/PRACTITIONER OR MEDICAL FACILITY FOR THE CURRENT DISABILITY/ILLNESS/INJURY?

M

M D D Y Y Y Y

YES NO UNKNOWN IF YES, WHAT WAS THE DATE OF FIRST TREATMENT?

SAMPLE

Fillable Printable Claim For Disability Insurance (Di) Benefits (De 2501)

Fillable Printable Claim For Disability Insurance (Di) Benefits (De 2501)