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Paid Family Leave (PFL) Supplemental Claim Certification

PFL benefits are payable for no more than the allowed maximum in a 12-month period. If you need to continue providing care for a family member, please complete the "PFL Claimant's Certification" below and follow the instructions for the box you check. This form must be returned within 20 days of the mailing date to the address shown below:

PFL Claimant's Certification

I continue to provide care for a seriously ill family member and have not returned to work. I have reported all wages, workers' compensation benefits, and other monies I received during the claim period to the Employment Development Department.

Check the box that applies to your claim and sign below.

Physician/Practitioner's Supplementary Certificate - Only required for Care Claims.

1. Are you still treating the patient named in the "PFL Claimant's Certification" above for the same condition that you previously certified?
   YES--Last Treatment Date: __________________________Blank line
   NO--Sign and return this form to the address shown below.
2. Does your patient continue to require care by the care provider for the condition referenced in 1 above?
   YES--Approximately how many total hours per day will patient continue to require care by a care provider? __________________________Blank line
   NO
3. Date you estimate your patient will no longer require care by the care provider:

   Blank line
4. Would disclosure of this information to your patient be medically or psychologically detrimental to the patient?
   YES
   NO

I certify that the above statements accurately describe my patient's medical condition and continuing need for care.

This form must be returned within 20 days of the mailing date to the address below.

DE 2525XFA Rev. 3 (7-21) (INTRANET)