DI / DE 2525XX

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EDD Employment Development Department State of California Logo

‎(800) 480-3287

PHYSICIAN/PRACTITIONER'S SUPPLEMENTARY CERTIFICATE

EDD Customer Account Number (EDDCAN) CLAIM ID SSN/ECN CED
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Claimant Instructions: If you are still disabled, contact your physician/practitioner immediately for completion of the Physician/Practitioner's Supplementary Certificate which must be submitted within twenty (20) days of the mailing date shown above or you may lose additional benefits.

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 EDD When completing this form, PLEASE PRINT WITH BLACK INK.

1. ARE YOU STILL TREATING THE PATIENT ? DATE OF LAST TREATMENT MM/DD/YYYY

2.

 WHAT CURRENT CONDITION(S) CONTINUES TO MAKE THE PATIENT DISABLED? (DIAGNOSIS REQUIRED, IF MADE)
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3. DATE OF NEXT APPOINTMENTMM/DD/YYYY

4.

 ICD DIAGNOSIS CODE(S) FOR DISABLING CONDITION THAT PREVENT THE PATIENT FROM PERFORMING HIS/ HER REGULAR OR CUSTOMARY WORK (REQUIRED)
EXAMPLE OF HOW TO COMPLETE ICD CODES ICD-9 _______-__________Blank line
ICD-10 _______-__________Blank line		 (Check only one box)
 PRIMARY
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SECONDARY
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SECONDARY
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SECONDARY
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ADDITIONAL QUESTIONS ON FOLLOWING PAGES

DE 2525XX Rev. 4 (10-16) (INTRANET)

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5.

 DESCRIBE HOW THE PATIENT'S PRESENT CONDITION/IMPAIRMENT PREVENTS HIM/HER FROM RETURNING TO HIS/HER REGULAR OR CUSTOMARY WORK.
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6.

 WHAT FACTORS OR COMPLICATIONS ARE DISABLING THE PATIENT LONGER THAN PREVIOUSLY ESTIMATED?
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7. IF PATIENT WAS HOSPITALIZED, PROVIDE DATES OF ENTRY AND DISCHARGE MM/DD/YYYY To MM/DD/YYYY
8. DATE AND TYPE OF SURGERY/PROCEDURE PERFORMED OR TO BE PERFORMED
MM/DD/YYYY __________________________________________________________________________Blank line
9A. ICD PROCEDURE CODE(S)
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9B. CPT CODE(S) (DO NOT INCLUDE MODIFIERS)
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10. CURRENT ESTIMATED DATE PATIENT (EVEN IF STILL UNDER TREATMENT) WILL BE ABLE TO PERFORM HIS/HER REGULAR OR CUSTOMARY WORK ("UNKNOWN", "INDEFINITE", ETC., NOT ACCEPTABLE)
MM/DD/YYYY
11. WOULD DISCLOSURE OF THE INFORMATION ON THIS FORM BE MEDICALLY OR PSYCHOLOGICALLY DETRIMENTAL TO YOUR PATIENT?

ADDITIONAL QUESTIONS AND SIGNATURE REQUIRED ON NEXT PAGE

DE 2525XX Rev. 4 (10-16) (INTRANET)

SAMPLE, this page for reference only

12. PHYSICIAN/PRACTITIONER'S LICENSE NUMBER
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13. STATE OR COUNTRY (IF NOT U.S.A.) THAT ISSUED THE LICENSE NUMBER ENTERED IN QUESTION 12
State __________ Blank lineCountry _______________________Blank line
14. PHYSICIAN/PRACTITIONER'S NAME
(First)
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(MI)
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(Last)
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(Suffix)
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15. PHYSICIAN/PRACTITIONER LICENSE TYPE
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16. SPECIALTY, IF ANY
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17. PHYSICIAN/PRACTITIONER'S ADDRESS
MAILING ADDRESS, PO BOX, OR NUMBER/STREET/SUITE#
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CITY
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STATE
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ZIP OR POSTAL CODE
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COUNTRY (IF NOT U.S.A.)
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18. COUNTY HOSPITAL/GOVERNMENT FACILITY ADDRESS
FACILITY NAME (IF APPLICABLE)
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FACILITY ADDRESS, NUMBER/STREET/SUITE#
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CITY
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STATE
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ZIP OR POSTAL CODE
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COUNTRY (IF NOT U.S.A.)
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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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19.PHYSICIAN/PRACTITIONER'S ORIGINAL SIGNATURE – RUBBER STAMP IS NOT ACCEPTABLE
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Signature
Date Signed
MM/DD/YYYY
Area Code and Phone Number
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Under sections 2116 and 2122 of the California Unemployment Insurance Code (CUIC), it is a violation for any individual who, with 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 $20,000. Section 1143 requires additional administrative penalties.

DE 2525XX Rev. 4 (10-16) (INTRANET)