DI / DE 2585BF

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

Authorization to Disclose Personal-Health Information to a Voluntary Plan Administrator

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Date:
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For Office Use Only:
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Claimant:
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Care Recipient:
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VP Administrator:
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We have received your claim for Paid Family Leave (PFL) benefits and believe that you are covered instead by your employer's voluntary plan. For reasons of confidentiality, we need an authorization signed by the care recipient to send the medical portion of your claim to your employer's voluntary plan administrator for consideration of payment.

Please do all of the following:

  1. Have the care recipient sign and date page 2 of this form. If the care recipient is a minor or is physically or mentally unable to sign and date page 2, it may be signed and dated by an authorized representative of the care recipient.
  2. Enter your Social Security number in the upper right corner of page 2. Without your Social Security number on page 2, we cannot release the necessary information to your voluntary plan.
  3. Return the enclosed form to our office within ten days.
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Program Representative
Paid Family Leave Office
PO Box 997017
Sacramento, CA 95899-7017
 

DE 2585BF Rev. 2 (11-21) (INTRANET)

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

Authorization to Disclose Personal-Health Information to a Voluntary Plan Administrator

For Office Use Only:
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Claimant:
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Care Recipient:
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VP Administrator:
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I, BlankLine hereby authorize the Employment Development Department (EDD) to disclose my personal health information to BlankLine for the purpose of determining the eligibility of BlankLine (my care provider) for Paid Family Leave (PFL) benefits.

I understand that this authorization applies to all personal-health information that I have already authorized health care providers to disclose to the EDD as well as to any personal-health information that I separately authorize them to disclose to the EDD in the future. Personal-health information may include a diagnosis and prognosis of my condition, the date it commenced, an estimate of the amount of care that I require from my care provider as a result of my condition, and a statement of facts regarding my condition. Disclosure of my personal-health information may include any mental or physical condition that I have, including AIDS/HIV and drug or alcohol addiction.

I understand that the EDD may disclose this information as authorized by the California Unemployment Insurance Code (CUIC) and that such re-disclosed information may no longer be protected.

I understand that I may revoke this authorization by notifying the EDD in writing at PO Box 997017, Sacramento, CA 95899-7017. Otherwise, it will be valid for 10 years from the date the EDD receives it or from the effective date of the claim associated with this authorization, whichever is later.

I understand that I may not revoke my authorization to avoid prosecution or to prevent the EDD's recovery of monies to which it is legally entitled. I also understand that I have the right to receive a copy of this authorization from the EDD if I request one by writing to the EDD at the address shown in the paragraph immediately above. I agree that photocopies of this authorization shall be as valid as the original.

Care Recipient's Signature:
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Date:
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An authorized representative signing on behalf of the care recipient must complete the following:

I, BlankLine, represent the care recipient in this matter as authorized by:

(For spouse or domestic partner, contact the EDD at 1-877-238-4373.)

Authorized Representative's Signature:
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Date:
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DE 2585BF Rev. 2 (11-21) (INTRANET)