Request For Additional Medical Information

PFL CLAIMANT'S NAME:

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For Office Use Only:

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PATIENT'S NAME:

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PATIENT FILE NUMBER:

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MAILING DATE:

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PATIENT'S DATE OF BIRTH:

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CLAIM EFFECTIVE DATE:

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Additional medical information is required to determine if the claimant named above is eligible to receive Paid Family Leave (PFL) benefits. Please provide responses to the following check-marked question(s) within seven working days of the mailing date shown above.

Blank Line Medical Director

What is (are) the diagnosis(es) for the International Classification of Diseases (ICD) code(s) provided?
1. DX:
  
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  ICD Code:
  
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2. DX:
  
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  ICD Code:
  
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3. DX:
  
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  ICD Code:
  
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What is (are) the International Classification of Diseases (ICD) code(s) for the diagnosis(es) provided for the patient?
1. ICD Code:
  
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  DX:
  
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2. ICD Code:
  
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  DX:
  
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3. ICD Code:
  
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  DX:
  
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DE 2547AF Rev. 5 (11-21) (INTRANET)

SAMPLE, this page for reference only

Please respond only to check-marked questions

Please describe the type of family care the PFL claimant needs to provide for your patient. For PFL purposes, "family care" includes but is not limited to, providing psychological comfort, and arranging "third party" care for a child, parent, parent-in-law, grandparent, grandchild, sibling, spouse, or registered domestic partner, as well as directly providing or participating in the medical care of that person.
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Has there been any recent change in the estimated number of hours per day (increase/decrease) that your patient needs family care?
1. Yes Blank line No Blank line
2. If so, please describe the change and the reason for the change.
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Why does this patient's diagnosis constitute a serious health condition requiring family care? For PFL purposes, a "serious health condition" is defined as an illness, injury, impairment or physical or mental condition that involves inpatient care in a hospital, hospice, residential health care facility, or continuing treatment or continuing supervision by a health care provider.
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What are the complications or circumstances that require your patient to need family care longer than normally expected for this medical condition?
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Is this patient under your direct care at this time? If yes, how often do you see the patient for the condition that you diagnosed on the medical certification?
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Please provide a detailed description of the care and treatment you are providing to this patient for the condition that you diagnosed on the medical certification.
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PFL benefits may be payable to the claimant through the patient's date of death. Our records indicate that the above-named patient is deceased. Please provide the patient's date of death.
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  MM/DD/YY

DE 2547AF Rev. 5 (11-21) (INTRANET)

SAMPLE, this page for reference only

Please provide the date your patient first required care.
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  MM/DD/YY
How many hours per day does this patient require care?
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  hours per day
What is the estimated date this patient will no longer require care?
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  MM/DD/YY

Complete this section before returning this form to the PFL mailing address

Would disclosure of this information be medically or psychologically detrimental to your patient?

Yes Blank line No Blank line

Signed:

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Printed Name:

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Your specialty, if any:

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License Number:

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Date:

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Business reply envelope provided Blank Space

DE 2547AF Rev. 5 (11-21) (INTRANET)

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DI / DE 2547AF

Request For Additional Medical Information