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

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

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

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
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
M
M
M
D
D
D
D
Y
Y
Y
Y
Y
Y
Y
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
DE 2501 Rev. 79 (10-16) (INTERNET) Page 3 of 7
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
250110164
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.
NUMBER/STREET/APARTMENT OR SPACE#, PO BOX OR PRIVATE MAIL BOX ADDRESSES NOT ACCEPTABLE.
(FIRST) (MI) (LAST)
CITY STATE ZIP CODE
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
DATE SIGNED
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
M
M
M
M
M
D
D
D
D
D
D
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
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
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
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.)
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
M
M
M
D
D
D
D
Y
Y
Y
Y
Y
Y
Y
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
SECONDARY
SECONDARY
ICD-9
ICD-10
EXAMPLE OF HOW TO
COMPLETE ICD CODES
ICD-9
ICD-10
.
.
3
G
2
0
0 1
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
M
M
M
D
D
D
D
Y
Y
. . . .
Y
Y
Y
Y
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
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