DI / DE 2547(D4)

SAMPLE, this page for reference only

NONINDUSTRIAL DISABILITY INSURANCE
PO BOX 2168
STOCKTON, CA 95201-2168
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Mailing Date
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RETURN TO:
NONINDUSTRIAL DISABILITY INSURANCE
PO BOX 2168
STOCKTON, CA 95201-2168
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‎ (866) 758-9768

REQUEST FOR MEDICAL INFORMATION

EDD Customer Account Number (EDDCAN) CLAIM ID SSN/ECN CED
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‎‎XXX-XX- Blank space
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Claimant Instructions: To avoid a delay in issuing any Disability Insurance (DI) payment(s) to you, please have The doctor to whom you are being referred complete this form and return it to us as soon as possible.

Physician/Practitioner Instructions: For faster processing, the physician/practitioner may complete and submit this form online at www.edd.ca.gov If this form is submitted online, you do not have to mail this form back to the Employment Development Department (EDD). When completing this form, PLEASE PRINT WITH BLACK INK.
  1. I attended the patient for the present medical problem
    From:
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    MM/DD/YYYY
    To:
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    MM/DD/YYYY
    At intervals of:
  2. Diagnosis (REQUIRED):
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    ICD Disease Code, Primary (REQUIRED):
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    ICD Disease Code, Secondary:
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    Findings (state nature, severity and bodily extent of the incapacitating disease or injury):
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    Type of treatment and/or medication rendered to patient:
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    History:
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  3. Diagnosis confirmed by (specify type of test or X-ray):
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  4. Is this patient now pregnant or has she been pregnant since the date of treatment as reported above?
    If "Yes," date pregnancy terminated or future EDC:
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    MM/DD/YYYY
    Is pregnancy normal?
    If "No," state the abnormal and involuntary complication causing maternal disability:
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DE 2547D4 Rev. 25 (10-16) (INTRANET)

SAMPLE, this page for reference only

For Office Use Only
EDDCAN
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CLAIM ID
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SSN/ECN
‎‎XXX-XX- Blank space
CED
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  1. Surgery: Date performed or to be performed:
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    MM/DD/YYYY
    Type of surgery:
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    ICD Procedure Code (REQUIRED):
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  2. Has the patient at any time during your attendance for this medical problem been incapable of performing his/her regular work?
    If "Yes," the disability commenced on:
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    MM/DD/YYYY
  3. APPROXIMATE date, based on your examination of patient, disability (if any) should end or has ended sufficiently to permit the patient to resume regular or customary work. Even if considerable question exists, make SOME “estimate.”
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    MM/DD/YYYY
    This is a requirement of the code, and claim will be delayed if such date is not entered. "Indefinite" or "don't know" will not suffice.
  4. Based on your examination of patient, is this disability the result of "occupation" either as an "industrial accident" or as an "occupational disease"? (This should include aggravation of pre-existing conditions by occupation.)
  5. Have you reported this OR A CONCURRENT DISABILITY to any insurance carrier as a Workers' Compensation claim?
    If "Yes," to whom?
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  6. Was or is patient confined as a registered bed patient in a hospital?
    Was patient treated in the surgical unit of a hospital or surgical clinic?
    If “Yes,” please provide name and address:
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  7. Date and hour entered as a registered bed patient and discharged from such hospital pursuant to your orders:
    ENTERED STILL CONFINED DISCHARGED
    on
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    MM/DD/YYYY
    at
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    AMPM
    on
    Blank line
    MM/DD/YYYY
    at
    Blank space
    AMPM
    on
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    MM/DD/YYYY
    at
    Blank space
    AMPM
  8. Would the disclosure of this information to your patient be medically or psychologically detrimental to the patient?
Physician/Practitioner’s Certification:
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 (CUIC) Section 2708.
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(TYPE OF PHYSICIAN/PRACTITIONER)
,
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(SPECIALTY, IF ANY)
licensed to practice by the State of
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Print or type physician/practitioner name as shown on license
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Original signature of attending physician/practitioner. Rubber stamp is not acceptable.
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Number and Street
City
Zip Code
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State License Number
Phone Number
Date of Signing

Under Section 2116 of the California Unemployment Insurance Code (CUIC), it is a violation for any individual who, with the 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 twenty thousand dollars. Section 1143 requires additional administrative penalties.

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

DE 2547D4 Rev. 25 (10-16) (INTRANET)