DI / DE 2547DF

SAMPLE, this page for reference only

EDD - PAID FAMILY LEAVE
PO BOX 997017
SACRAMENTO CA 95899-7017

‎1-877-238-4373

RETURN TO :

PAID FAMILY LEAVE
PO BOX 997017
SACRAMENTO CA 95899-7017
PFL CLAIMANT
STREET ADDRESS
CITY, STATE, ZIP CODE
PATIENT/CARE RECIPIENT :
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CARE RECIPIENT DATE OF BIRTH :
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CLAIM EFFECTIVE DATE :
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REQUEST FOR MEDICAL INFORMATION

For Office Use Only:
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MAILING DATE:
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In order that any Paid Family Leave (PFL) benefits for which you are entitled can be paid without undue delay, please have your family member's (care recipient's) complete this form and return it to us at his/her earliest convenience.

Please be sure that your family member signs and returns the Authorization for Disclosure of Personal Health Information included with this form.

Physician's Medical Statement
1.
I attended this patient
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(Your Patient's Name)
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Date of Birth
for the present medical problem from
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(MM/DD/YYYY)
to
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(MM/DD/YYYY)
at intervals of
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PATIENT'S MEDICAL FILE NUMBER
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2.
Findings (state nature, severity, and bodily extent of the incapacitating disease or injury):
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3.
Please provide your patient's diagnosis and the primary (and secondary) ICD code.
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4.
Does this patient require care by the PFL claimant?
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5.
First date care was needed
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6.
What is your patient's expected recovery date?
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7.
What is the estimated date that your patient will no longer require care from the PFL claimant?
 
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Date

(Claim processing will be delayed if no expected recovery and estimated date is provided).
8.
How was your patient's diagnosis confirmed? Please specify the type of test or X-ray used.
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DE 2547DF Rev. 3 (11-21) (INTRANET)

SAMPLE, this page for reference only

For Office Use Only:
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MAILING DATE:
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9.
Was or is this patient confined as a registered hospital inpatient?
Yes
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No
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10.
Was this patient treated in the surgical unit of a hospital or in a surgical clinic?
Yes
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No
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Hospital/surgical clinic admission date
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Hospital/surgical clinic discharge date
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Please provide name/address of treating facility:
 
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Address
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City/State
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ZIP Code
11.
What is the current estimated hours per day that this patient requires care from the PFL claimant? Has there been any recent change in the need for care (estimated hours per day)?
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12.
Please describe the specific physical and/or psychological care your patient needs from the PFL claimant.
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13.
Would disclosure of this information to your patient be medically or psychologically detrimental?
Yes
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No
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I hereby certify that based on my examination, the above statements describe my patient's medical condition (if any) and the estimated duration thereof, and that I am a
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(TYPE OF PHYSICIAN/PRACTITIONER SPECIALTY)
licensed
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(License No.)
to practice by the state (or Country if not U.S.A.) of
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Type or print physician/practitioner name as listed on the physician/practitioner license
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Physician/practitioner original signature
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Address
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City     State     ZIP Code
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Phone
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Date

Under Section 2116 and 3305 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 Paid Family Leave (PFL) benefits, whether for the maker or for any other person and is punishable by imprisonment and/or a fine not exceed 25 percent of the benefits paid as a result of the false certification. Sections 1143 and 3305 impose 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 2547DF Rev. 3 (11-21) (INTRANET)

SAMPLE, this page for reference only

For Office Use Only:
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MAILING DATE:
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CARE RECIPIENT’S AUTHORIZATION FOR DISCLOSURE OF PERSONAL HEALTH INFORMATION

I authorize my physician or practitioner to disclose my current personal health information to my care provider and to the Employment Development Department (EDD).

I understand that such information includes a diagnosis and prognosis of my current condition, the date it commenced, and an estimation of the amount of care that I require from my care provider as a result of my current condition. I further understand that disclosure of my personal heath information may include my AIDS/HIV status, drug or alcohol addiction, or any other physical or mental condition.

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

I understand that unless I inform the EDD in writing at PO Box 997017, Sacramento, CA 95899-7017, that I wish to revoke this authorization, it will be valid for 10 years from the date the EDD receives it or the effective date of this claim, whichever is later. I understand that I have the right to receive a copy of this authorization form from the EDD if I request one in writing.

I make this authorization to support my care provider's claim for Paid Family Leave (PFL) benefits. 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.

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Care recipient's name (Print your name)
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Care recipient's signature (Sign your name)
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Authorized representative (Sign here if the care recipient is unable to provide a signature)
Date ___________________ Blank line

DE 2547DF Rev. 3 (11-21) (INTRANET)