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Blank De2501Fc PDF Form

The DE 2501FC form is used to claim Paid Family Leave (PFL) care benefits in California. This form is essential for individuals providing care to a family member or loved one who has a serious health condition. Proper completion of the form ensures that the claim is processed efficiently and accurately.

To begin filling out the DE 2501FC form, please click the button below.

Article Guide

The DE 2501FC form is an essential document for individuals seeking Paid Family Leave (PFL) care benefits in California. This form facilitates the process of claiming benefits for those who provide care to a seriously ill family member. It includes several key sections that must be completed accurately to ensure timely processing of claims. Part C requires the care recipient to sign a statement, unless they are unable due to physical or mental conditions, in which case an authorized representative can step in. The physician or practitioner of the care recipient must fill out Part D, certifying the medical necessity for care. This certification can be done electronically or through a physical form submission. For the best results, submitting the completed forms electronically via SDI Online is recommended, although mail submissions are also accepted. Accurate completion of all required sections, including personal details and medical disclosures, is crucial. Failure to provide complete information may lead to delays or denial of benefits, emphasizing the importance of thoroughness in this process.

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Claim for Paid Family Leave (PFL) Care Benefits

Enter your receipt number here.

PART C – INSTRUCTIONS FOR PFL CARE CLAIMS

The care recipient (the person for whom you are providing care) must do the following: Complete and sign “Part C – Statement of Care Recipient.” If the care recipient is physically or mentally unable to sign, call PFL at 1-877-238-4373 for instructions.

The care recipient’s physician/practitioner must complete “Part D – Physician/ Practitioner’s Certification” either electronically in SDI Online, or by completing and signing page 3 of Claim for Paid Family Leave (PFL) Care Benefits (DE 2501FC). If the care recipient is under the care of an accredited religious practitioner, call PFL at 1-877-238-4373 for the proper form Practitioner’s Certification for Paid Family Leave Benefits (DE 2502F).

The easiest way to have your claim processed is to submit the completed forms electronically in SDI Online as an attachment. If submitting by mail, send to the following address: Paid Family Leave, PO Box 997017, Sacramento, CA 95899-7017. If submitting electronically, return to the Homepage of your SDI Online account. Select New Claim from the Menu, and select Submit Electronic Paid Family Leave Care Attachment.

PART C – STATEMENT OF		(MAY BE COMPLETED BY CLAIMANT IF CARE RECIPIENT IS MENTALLY OR PHYSICALLY UNABLE TO DO SO.
	CARE RECIPIENT	MUST BE SIGNED BY CARE RECIPIENT OR CARE RECIPIENT’S AUTHORIZED REPRESENTATIVE.)
C1.	CARE PROVIDER SSN	C2. RECIPIENT’S DATE OF BIRTH		C3. RECIPIENT’S PHONE NUMBER		C4. RECIPIENT’S GENDER
						MALE	FEMALE

C5.	LEGAL NAME OF CARE RECIPIENT (FIRST, MIDDLE INITIAL, LAST)

C6.	CARE RECIPIENT’S RESIDENCE ADDRESS
CITY		STATE/PROV.	ZIP OR POSTAL CODE		COUNTRY (IF NOT U.S.A.)

C7. CONFIRMATION OF MEDICAL DISCLOSURE AUTHORIZATION. I authorize my physician/practitioner to disclose my current personal-health information to my care provider and to the California Employment Development Department (EDD). I further understand that copies of my signature below are as valid as the original.

Care Recipient’s Signature (DO NOT PRINT)

_______________________________________________________________________________	Date Signed
C8. Authorized Representative signing on behalf of care recipient must complete the following: I,	, represent the care recipient in
this matter as authorized by parental right power of attorney (attach copy) court order (attach copy) (For spouse or domestic partner, contact EDD).
Authorized Representative’s Signature (DO NOT PRINT)
_______________________________________________________________________________	Date Signed

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Enter your receipt number here.

LEFT BLANK INTENTIONALLY

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Medical certifications must be completed by a licensed physician or practitioner authorized to certify to a patient’s disability/serious health condition pursuant to California Unemployment Insurance Code Section 2708.

Enter your receipt number here.

PART D – PHYSICIAN/PRACTITIONER’S CERTIFICATION

D1.	PFL CLAIMANT’S (CARE
	PROVIDER’S) SOCIAL
	SECURITY NUMBER		D2. PFL CLAIMANT’S NAME (FIRST, MIDDLE INITIAL, LAST)

D3.	PATIENT’S DATE OF BIRTH		D4. DOES YOUR PATIENT REQUIRE CARE BY THE CARE PROVIDER?
			YES	NO (SKIP TO D15)

D5.	PATIENT’S NAME (FIRST, MIDDLE INITIAL, LAST)

D6.	DIAGNOSIS OR, IF NOT YET DETERMINED, A DETAILED STATEMENT OF SYMPTOMS

D7.	PRIMARY ICD CODE		D8. SECONDARY ICD CODES					D9. DATE PATIENT’S CONDITION COMMENCED

			D11. DATE YOU ESTIMATE PATIENT WILL NO LONGER REQUIRE CARE BY
D10.	FIRST DATE CARE NEEDED		THE CARE PROVIDER					D12. DATE YOU EXPECT RECOVERY
					PERMANENT CARE REQUIRED			NEVER

D13.	APPROXIMATELY HOW MANY TOTAL HOURS PER DAY WILL PATIENT REQUIRE CARE BY A CARE PROVIDER?
HOURS		COMMENTS

D14.	WOULD DISCLOSURE OF THE MEDICAL INFORMATION ON THIS					D15. PHYSICIAN/		D16. STATE OR COUNTRY (IF NOT U.S.A.) IN WHICH
	CERTIFICATE BE MEDICALLY OR PSYCHOLOGICALLY DETRIMENTAL TO					PRACTITIONER’S		PHYSICIAN/PRACTITIONER IS LICENSED TO
	YOUR PATIENT?					LICENSE NUMBER		PRACTICE
	YES	NO

D17.	PHYSICIAN/PRACTITIONER’S NAME (FIRST, MIDDLE INITIAL, LAST)

D18.	PHYSICIAN/PRACTITIONER’S ADDRESS (POST OFFICE BOX IS NOT ACCEPTABLE AS THE SOLE ADDRESS)
CITY			STATE/PROV.	ZIP OR POSTAL CODE			COUNTRY (IF NOT U.S.A.)

D19.	TYPE OF PHYSICIAN/PRACTITIONER					D20. SPECIALTY (IF ANY)

D21.	Physician/Practitioner’s Certification:
	I certify under penalty of perjury that this patient has a serious health condition and requires a care provider. 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 section 2708.
	Original Signature of physician/practitioner –
	RUBBER STAMP IS NOT ACCEPTABLE
	__________________________________________________________________________
	PHYSICIAN/PRACTITIONER’S PHONE NUMBER					DATE SIGNED

Under sections 2116 and 2122 of the California Unemployment Insurance Code, 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. Sections 1143 and 3305 require additional administrative penalties.

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FEDERAL PRIVACY ACT. The EDD requires disclosure of Social Security numbers on a mandatory basis to comply with California Unemployment Insurance Code, sections 1253 and 2627; with California Code of Regulations, Title 22, sections 1085, 1088, and 1326; with Code of Federal Regulations, Title 20, Part 604; and with U.S. Code, Title 8, sections 1621, 1641, and 1642.

INFORMATION COLLECTION AND ACCESS. State law requires the following information to be provided when collecting information from individuals:

Agency Name:

Employment Development Department (EDD)

Title of Official Responsible for Information Maintenance:

Manager, EDD Paid Family Leave Office

Local Contact Person:

Manager, EDD Paid Family Leave Office

Address and Telephone Number:

The address and phone number of Paid Family Leave will appear on the Notice of Computation (DE 429D), issued at the time your benefit determination is made.

Maintenance of the Information is authorized by:

California Unemployment Insurance Code, sections 2601 through 3306.

California Code of Regulations, Title 22, sections 2706-1, 2706-3, 2708-1, and 2710-1.

Consequences of not providing all or any part of the requested information:

•Failure to supply any or all information may cause delay in issuing benefit payments or may cause you to be denied benefits to which you are entitled.

•If you willfully make a false statement, representation, or knowingly withhold a material fact to obtain or increase any benefit or payment, the EDD will disqualify you from receiving benefits and/or services and may initiate criminal prosecution against you.

Principal purpose(s) for which the information is to be used:

•To determine eligibility for Paid Family Leave benefits.

•To be summarized and published in statistical form for the use and information of government agencies and the public. (Neither your name and identification nor the name and identification of the care recipient will appear in publications.)

•To be used to locate persons who are being sought for failure to provide child or spousal support.

•To be used by other governmental agencies to determine eligibility for public social services under the provisions of California Welfare and Institutions Code, Division 9.

•To be used by the EDD to carry out its responsibilities under the California Unemployment Insurance Code.

•To be exchanged pursuant to California Unemployment Insurance Code, section 322, and California Civil Code, section 1798.24, with other governmental departments and agencies, both federal and state, which are concerned with any of the following:

(1)Administration of an unemployment insurance program.

(2)Collection of taxes which may be used to finance unemployment insurance or disability insurance.

(3)Relief of unemployed or destitute individuals.

(4)Investigation of labor law violations or allegations of unlawful employment discrimination.

(5)The hearing of workers’ compensation appeals.

(6)Whenever necessary to permit a state agency to carry out its mandated responsibilities where the use to which the information will be put is compatible with the purpose for which it was gathered.

(7)When mandated by state or federal law. Disclosures under California Unemployment Insurance Code, section 322, will be made only in those instances in which it furthers the administration of the programs mandated by that Code.

•Pursuant to California Unemployment Insurance Code, sections 1095 and 2714, information may be revealed to the extent necessary for the administration of public social services or to the Director of Social Services or his/her representatives.

•Information shall be disclosed to authorized agencies in accordance with California Unemployment Insurance Code, sections 1095 and 2714.

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➤ PDF File

Form Specifications

Fact Name	Description
Form Purpose	The DE2501FC form is used to claim Paid Family Leave (PFL) care benefits in California.
Governing Law	The form is governed by the California Unemployment Insurance Code, specifically sections 2708 and 1253.
Care Recipient's Responsibility	The care recipient must complete and sign “Part C – Statement of Care Recipient” unless unable to do so.
Physician's Role	A physician or practitioner must complete “Part D – Physician/Practitioner’s Certification” to certify the need for care.
Submission Method	Claims can be submitted electronically via SDI Online or by mail to the designated address in Sacramento, CA.
Authorized Representative	If the care recipient cannot sign, an authorized representative may sign on their behalf, with proper documentation.
Medical Disclosure	The care recipient must authorize their physician to disclose personal health information for the claim.
Fraud Penalties	False certification of medical conditions can result in criminal prosecution and fines under California law.
Information Collection	Information collected is used to determine eligibility for benefits and may be shared with other governmental agencies.

De2501Fc: Usage Guidelines

Completing the DE 2501FC form is an essential step in the process of claiming Paid Family Leave benefits. It is important to carefully follow the instructions to ensure all necessary information is accurately provided. The following steps outline how to fill out the form correctly.

Enter your receipt number at the top of the form.
In Part C, the care recipient must complete and sign the “Statement of Care Recipient.” If they are unable to sign, contact PFL at 1-877-238-4373 for guidance.
The care recipient's physician or practitioner must fill out “Part D – Physician/Practitioner’s Certification.” This can be done electronically through SDI Online or by completing and signing page 3 of the form.
If the care recipient is under the care of an accredited religious practitioner, call PFL at 1-877-238-4373 for the appropriate form.
To expedite processing, submit the completed forms electronically via SDI Online. If mailing, send the form to: Paid Family Leave, PO Box 997017, Sacramento, CA 95899-7017.
If submitting electronically, log into your SDI Online account, return to the Homepage, select “New Claim” from the Menu, and then select “Submit Electronic Paid Family Leave Care Attachment.”
In Part C, fill in the care recipient's Social Security Number, date of birth, phone number, gender, and legal name.
Provide the care recipient's residence address, including city, state, ZIP code, and country (if not U.S.A.).
Confirm the medical disclosure authorization by signing and dating the section provided.
If an authorized representative is signing on behalf of the care recipient, they must complete their details and sign the form as well.
In Part D, the physician/practitioner should fill in the claimant’s Social Security Number and name, the patient’s date of birth, and indicate if the patient requires care.
Provide the patient’s name, diagnosis, primary and secondary ICD codes, and the dates related to the patient's condition.
Indicate the estimated duration of care needed and how many hours per day the patient will require care.
The physician/practitioner must sign and date the certification, ensuring that their signature is original, as rubber stamps are not acceptable.

Once the form is completed, ensure all sections are filled out accurately. Review the information for any errors before submitting it electronically or by mail. Following these steps will help facilitate a smoother claims process.

Your Questions, Answered

What is the DE 2501FC form?

The DE 2501FC form is used to claim Paid Family Leave (PFL) care benefits in California. This form is specifically for individuals who are providing care to a family member with a serious health condition. It requires information from both the care provider and the care recipient, including medical certification from a physician or practitioner.

Who needs to sign the DE 2501FC form?

The care recipient must complete and sign “Part C – Statement of Care Recipient.” If the care recipient is unable to sign due to physical or mental limitations, an authorized representative can sign on their behalf. Additionally, a licensed physician or practitioner must complete “Part D – Physician/Practitioner’s Certification” to verify the care recipient’s condition.

How should I submit the DE 2501FC form?

You can submit the DE 2501FC form electronically through the SDI Online system, which is the preferred method. If you choose to submit by mail, send the completed form to Paid Family Leave, PO Box 997017, Sacramento, CA 95899-7017. Ensure that all parts of the form are filled out completely to avoid delays.

What if the care recipient is under the care of a religious practitioner?

If the care recipient is being treated by an accredited religious practitioner, you should contact PFL at 1-877-238-4373 for guidance on the appropriate certification form, known as the Practitioner’s Certification for Paid Family Leave Benefits (DE 2502F).

What information is required from the physician or practitioner?

The physician or practitioner must provide details about the care recipient's diagnosis, the duration of care needed, and confirm that the patient requires care. They must also certify that they are authorized to provide this information under California law. This includes signing the form and providing their license number and contact information.

What happens if I don’t provide all the requested information?

Failing to provide complete information may delay your benefit payments or result in denial of benefits. If you knowingly withhold information or provide false statements, it could lead to disqualification from receiving benefits and potential legal consequences.

How does the information on the DE 2501FC form get used?

The information collected through the DE 2501FC form is primarily used to determine eligibility for Paid Family Leave benefits. It may also be summarized for statistical purposes, shared with other governmental agencies for various administrative functions, and used to ensure compliance with California’s unemployment insurance laws.

Common mistakes

Incomplete Information: Many individuals fail to provide all necessary details, such as the care recipient's legal name or Social Security number. Omitting this information can lead to delays or denials of benefits.
Incorrect Signatures: The care recipient must sign the form, or an authorized representative must sign on their behalf. Some people neglect to ensure that the correct person has signed, which can invalidate the claim.
Failure to Include Medical Certification: The physician or practitioner’s certification is crucial. Some applicants mistakenly submit the form without this certification, which is required to establish the need for care.
Improper Submission Method: Submitting the form by mail rather than electronically can slow down the processing time. Many people do not realize that electronic submission is often faster and more efficient.

Documents used along the form

The DE 2501FC form, which is used to claim Paid Family Leave (PFL) Care Benefits, is often accompanied by several other important documents. Each of these forms serves a specific purpose in the claims process, ensuring that the necessary information is provided for eligibility determination and benefit processing. Below is a list of commonly associated forms.

DE 2502F: This is the Practitioner’s Certification for Paid Family Leave Benefits. It is required when the care recipient is under the care of an accredited religious practitioner. The form must be completed to confirm the care recipient’s need for care.
DE 2501: This is the Claim for Disability Insurance Benefits form. It may be used in situations where the care recipient is unable to work due to their serious health condition. This form helps to establish the recipient’s eligibility for disability benefits.
DE 429D: This is the Notice of Computation. It provides details about the benefit determination, including the amount and duration of benefits awarded. This form is essential for understanding the financial aspects of the claim.
DE 2511: This is the Claim for Paid Family Leave Benefits for Family Care. It is used when a claimant is seeking benefits to care for a family member with a serious health condition. This form outlines the specifics of the care being provided.
DE 2512: This is the Claim for Paid Family Leave Benefits for Bonding. It is applicable for individuals taking leave to bond with a new child. This form is crucial for those who qualify under the bonding provision of the PFL program.
Power of Attorney Documentation: If the care recipient is unable to sign the forms, a power of attorney document may be necessary. This document grants authority to an authorized representative to act on behalf of the care recipient in completing and signing the required forms.

Submitting the appropriate forms along with the DE 2501FC ensures a smoother claims process. It is critical to complete and submit all necessary documentation accurately and promptly to avoid delays in receiving benefits. Make sure to check that all forms are filled out correctly before submission.

Similar forms

DE 2501 - This is the standard form for claiming Disability Insurance benefits. Like the DE 2501FC, it requires a medical certification from a physician or practitioner to validate the claim for benefits.
DE 2502F - This form is used for the Practitioner’s Certification for Paid Family Leave Benefits. It is similar to the DE 2501FC in that it involves a medical professional certifying the need for care, but it specifically addresses cases involving accredited religious practitioners.
DE 2500 - This form is for reporting a claim for Disability Insurance benefits. Both forms require the claimant to provide personal information and medical documentation to support their claim.
DE 429D - The Notice of Computation is issued after a claim is processed. It shares similarities with the DE 2501FC in that it communicates important information regarding eligibility and benefits.
DE 2520 - This form is for the Request for Paid Family Leave Benefits. Like the DE 2501FC, it requires documentation to substantiate the need for leave due to family care responsibilities.
DE 2570 - This form is used to report a change in the claimant’s circumstances. It is similar to the DE 2501FC in that both require timely updates to ensure accurate processing of claims.
DE 2580 - This is the Claim for Disability Insurance Benefits for a Self-Employed Individual. Both forms require similar medical certifications and personal information to support claims.
DE 2581 - This form is for the Request for Information Regarding Disability Insurance Benefits. It shares the requirement for medical documentation similar to the DE 2501FC.
DE 2593 - This is the Claim for Disability Insurance Benefits for a State Employee. Like the DE 2501FC, it involves certification from a healthcare provider to validate the claim.
DE 2615 - This form is for the Certification of a Serious Health Condition. It parallels the DE 2501FC in that it requires detailed medical information to substantiate claims for family leave.

Dos and Don'ts

When filling out the DE 2501FC form for Paid Family Leave (PFL) Care Benefits, it’s important to follow certain guidelines to ensure your application is processed smoothly. Here’s a list of things you should and shouldn’t do:

Do ensure the care recipient completes and signs “Part C – Statement of Care Recipient.”
Do contact PFL at 1-877-238-4373 if the care recipient cannot sign due to physical or mental limitations.
Do have the care recipient’s physician complete “Part D – Physician/Practitioner’s Certification.”
Do submit the forms electronically via SDI Online for quicker processing.
Don't forget to include the care recipient’s legal name and residence address on the form.
Don't use a rubber stamp for the physician/practitioner’s signature; it must be an original signature.
Don't leave any required fields blank, as this may delay your application or result in denial of benefits.

Misconceptions

Understanding the DE 2501FC form, which is used for claiming Paid Family Leave (PFL) Care Benefits, is essential for caregivers. However, several misconceptions exist that can lead to confusion. Here are some of the most common misunderstandings:

Misconception 1: The care recipient must fill out the entire form themselves.

In reality, if the care recipient is unable to sign due to physical or mental limitations, an authorized representative can complete the form on their behalf. This allows for flexibility in the process.

Misconception 2: Only a doctor can certify the care recipient’s condition.

While a physician or practitioner is typically required to complete the certification, if the care recipient is under the care of an accredited religious practitioner, different forms may apply. It’s important to contact PFL for guidance in such cases.

Misconception 3: Submitting the form by mail is the only option.

You can submit the DE 2501FC form electronically through the SDI Online system. This method is often quicker and can expedite the processing of your claim.

Misconception 4: The form does not require a signature from the care recipient.

A signature is necessary, unless the care recipient is unable to sign. In such cases, the authorized representative must provide their signature along with documentation proving their authority.

Misconception 5: There are no consequences for incomplete information.

Failing to provide all required information can lead to delays in benefits or even denial of your claim. It’s crucial to ensure that all sections are filled out accurately.

Misconception 6: Medical certifications can be completed by anyone.

Only licensed physicians or practitioners authorized to certify a patient's serious health condition can complete the medical certification section. This ensures that the information is credible and reliable.

Misconception 7: The information provided will be made public.

Your personal information is protected. The data collected is used for determining eligibility and will not be published in a way that identifies you or the care recipient.

By clarifying these misconceptions, caregivers can navigate the process more effectively and ensure they receive the benefits they are entitled to. Understanding the requirements and procedures can alleviate stress during what is often a challenging time.

Key takeaways

Filling out and using the DE 2501FC form for Paid Family Leave (PFL) Care Benefits can be a straightforward process if you keep the following key points in mind:

Part C Completion: The care recipient must complete and sign “Part C – Statement of Care Recipient.” If they cannot sign due to physical or mental limitations, contact PFL for guidance.
Medical Certification: A licensed physician or practitioner must fill out “Part D – Physician/Practitioner’s Certification.” This can be done electronically or by completing the paper form.
Religious Practitioners: If the care recipient is under the care of a religious practitioner, specific forms are required. Contact PFL for the correct documentation.
Electronic Submission: Submitting the completed forms electronically through SDI Online is the most efficient method for processing your claim.
Mailing Instructions: If you choose to mail your forms, send them to the address provided: Paid Family Leave, PO Box 997017, Sacramento, CA 95899-7017.
Authorized Representative: If someone is signing on behalf of the care recipient, they must have proper authorization, such as a power of attorney.
Information Accuracy: Ensure all information provided, including Social Security numbers and medical details, is accurate to avoid delays in processing.
Consequences of Incomplete Information: Failing to provide all requested information may result in delays or denial of benefits.
Privacy Considerations: Understand that personal health information may be disclosed to necessary parties for the administration of your claim.

By following these guidelines, you can help ensure a smoother application process for Paid Family Leave Care Benefits. Remember, support is available if you encounter any difficulties.