DI / DE 1850J

SAMPLE, this page for reference only

 

EDD Employment Development Department State of California Logo

Declaration of Claimant (Care Provider) Acting as Authorized Representative for Incapacitated or Deceased Care Recipient

Instructions:
  • Care Recipient Deceased - If the person receiving care (care recipient) is now deceased:
    • The claimant (care provider) shall complete Sections A, B, and E.
  • Care Recipient Mentally Incapacitated - If the person receiving care (care recipient) is mentally incapacitated:
    • The claimant (care provider) shall complete Sections A and E.
    • The care recipient's physician/practitioner shall complete Section C.
  • Care Recipient Physically Incapacitated - If the person receiving care (care recipient) is physically incapacitated:
    • The claimant (care provider) shall complete Sections A, D, and E.
    • The care recipient's physician/practitioner shall complete Section C.
Section A - Claimant's Information and Certification
Claimant's (Care Provider's) Social Security Number:
Blank Line
Claimant's (Care Provider's) Name:
Blank Line
Claim Effective Date:
Blank Line
Person Receiving Care (Care Recipient's) Name:
Blank Line
I,
Blank line
Name of Claimant (Care Provider)
, authorize the Employment Development Department (EDD) to disclose my personal information, which is contained on this form, to the care recipient and the physician/practitioner certifying hereon to the care recipient's mental or physical incapacity.
Signature of Claimant (Care Provider):
Blank Line
Date Signed:
Blank Line
Section B - Care Recipient Deceased
I declare that the person receiving care (care recipient) died on   Blank Line   Month, Day, Year 
at
Blank Line ,
City
Blank Line ,
County
Blank Line .
State

DE 1850J Rev. 1 (2-22) (INTERNET)

SAMPLE, this page for reference only

Section C - Physician/Practitioner's Certification for Mentally or Physically Incapacitated Care Recipient
I
Blank line
Physician Practitioner's Name
hereby certify that the patient (care recipient) named in this document is under my care and based on my examination, the care recipient is: (select one)
to sign documents or authorize release of their medical records.
Blank Line
Physician/Practitioner's Name as Shown on License
Blank Line
Physician/Practitioner Signature
Blank Line
Address
Blank Line
State License Number
Blank Line
Phone Number
Blank Line
Date
Section D - Care Recipient's Authorized Representative/Agent Appointment
I
Blank line
Person Receiving Care (Care Recipient's) Name
, residing at
Blank line
City
Blank Line ,
County
Blank Line
State
hereby appoint
Blank Line
Authorized Representative/Agent's Name
as my true and lawful representative/agent.
The above named authorized representative/agent is authorized to sign documents on my behalf and release my medical records to my care provider (claimant) and to the Employment Development Department (EDD) for purposes of establishing my care provider's claim for Paid Family Leave (PFL) or Non-industrial Disability Insurance (NDI) - Family Care Leave benefits.
The authorized representative/agent must sign below in the presence of two witnesses.
Blank Line
Care Recipient's Signature - Signed by the Authorized Representative/Agent
Blank Line
Date
By
Blank line 
Authorized Representative Agent/Claimant's Signature
Blank Line
Witness' Signature
Blank Line
Witness' Signature
Blank Line
Witness' Address
Blank Line
Witness' Address

DE 1850J Rev. 1 (2-22) (INTERNET)

SAMPLE, this page for reference only

Section E - Authorized Representative/Agent's Declaration
I,
Blank line
Authorized Representative/Agent's Name
residing at
Blank line
Street Address
Blank line,
City, State, ZIP Code
declare that I am
Blank lineof
Relationship to Person Receiving Care (Care Recipient)
Blank line .
Person Receiving Care (Care Recipient's) Name
I declare that I am the care provider (claimant) and authorized representative/agent of the person receiving care (care recipient) named in this document. I am legally authorized to sign documents on behalf of the care recipient and release the medical records of the care recipient for purposes of establishing eligibility for Paid Family Leave (PFL) or Non-industrial Disability Insurance (NDI) - Family Care Leave benefits. I understand that this Declaration is for the sole purpose of releasing the care recipient's medical records pertaining to the care provider's (claimant's) Paid Family Leave (PFL) or Non-industrial Disability Insurance (NDI) - Family Care Leave benefits. I accept the responsibilities and obligations arising from acting on behalf of the care recipient in accordance with the California Unemployment Insurance Code (CUIC) and authorized regulations pertaining thereto.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Executed at
Blank line ,
City
Blank line,
County
Blank line 
State
 
Blank Line
Authorized Representative/Agent's Signature
 
Blank Line
Date

DE 1850J Rev. 1 (2-22) (INTERNET)