Form DE2501 "Claim for Disability Insurance (Di) Benefits" - California

What Is а DE 2501 Form?

Form DE 2501, Claim for Disability Insurance (DI) Benefits, is a form to request, by mail, worker-funded benefits to eligible workers who have a full or partial loss of wages due to disabilities that are not work-related.

Alternate Name:

  • California Disability Form.

Your employer will be notified if you submit a DI claim, but your personal information is confidential and will not be shared. The California Unemployment Insurance Code (CUIC) states that any illness or injury - either physical or mental - that prevents you from doing regular work is a disability. This also includes surgeries and complications related to pregnancy or childbirth.

The California Disability form was issued by the Employment Development Department on . A printable DE 2501 Claim Form is available for download below.

ADVERTISEMENT

How to Fill out Form DE 2501?

Form DE 2501 can not be used if you are insured by a voluntary plan or filing for non-industrial disabilities insurance benefits. In order to be eligible, you must be unable to do regular work for at least 8 days, be employed or actively looking for work at the time of the disability, have lost wages due to the disability, and/or be under the care or treatment of a licensed physician. Claimants must complete the form within 49 days of becoming disabled and provide medical certification of the disability.

Step-by-step DE 2501 Form instructions are provided below. Submit your claim no earlier than 9 days and no later than 49 days after your disability begins, or you may lose eligibility.

  1. Gather the required information. You must make sure to provide the following information: first and last name, social security number, California Driver License number, most current employer's business name, phone number, and mailing address (as stated on your W-2 or paystub), last date you worked your regular duties and hours or date you began working at less than full duty or modified duty. Provide the following information on the form only if it applies to you: any wages you received or expect to receive from your employer, any workers' compensation claim information, if applicable, and provide the name, address, and phone number of any in-patient treatment at an alcoholic recovery home or drug-free facility.
  2. Complete the HIPAA Authorization and Part A - Claimant's Statement (pages 1-4), of the DE 2501 Form. Write clearly in the spaces provided, use black ink only, and sign the form where indicated.
  3. After completing Part A, contact your physician/practitioner about completing, signing, and submitting your medical certification (Part B - Physician/Practitioner's Certificate, pages 5-7). You are responsible for obtaining a Physician/Practitioner Certification for your disability. Talk to your physician/practitioner about their process for submitting a DI claim. They do not all follow the same process. Some offices may have you mail in Part B, while others may mail in Part B themselves.

Where to Mail Form DE 2501?

To submit the claim, attach a postage stamp to a pre-addressed envelope and mail the completed paper claim form to the following address: State of California Employment Development Department, PO Box 989777, West Sacramento, CA 95798-9777

If you are not eligible for benefits, a Notice of Determination (DE 1080CZ) will subsequently be mailed to you. You must meet eligibility requirements to receive benefits. If you are disqualified from receiving benefits, you will receive an Appeal Form (DE 1000A) with your disqualification notice. You have the right to appeal any decision, in writing, within 30 days of the mailing date of the disqualification notice.

ADVERTISEMENT

Download Form DE2501 "Claim for Disability Insurance (Di) Benefits" - California

3269 times
Rate (3.9 / 5) 45 votes
Claim for Disability Insurance (DI) Benefits
The State Disability Insurance (SDI) program provides worker-funded benefits to eligible workers who have a
full or partial loss of wages due to disabilities that are not work related. The California Unemployment Insurance
Code (CUIC) states that a disability is any illness or injury, either physical or mental, that prevents you from
doing your regular or customary work. Disability also includes elective surgery and disabilities related to
pregnancy or childbirth.
Please read instruction and information pages (A through D) before completing the enclosed forms.
For faster processing, file your claim using SDI Online at www.edd.ca.gov. If you file online, do NOT mail this
form to the Employment Development Department (EDD).
DO NOT COMPLETE THIS FORM IF YOU ARE:
Insured by a Voluntary Plan. Ask your employer for the proper forms.
Filing for Non-Industrial Disability Insurance benefits. State government employees refer to your
personnel office.
If you cannot complete this form due to your disability, or if you are an authorized representative filing for benefits
on behalf of an incapacitated or deceased claimant, call 1-800-480-3287 or visit the EDD website to send an
online message using Ask EDD at https://askedd.edd.ca.gov.
HOW TO COMPLETE THIS FORM
Use black ink only.
Type or write clearly within the boxes provided.
Enter your Social Security number on all pages of the claim form including attachments.
Do not fax the form.
Mail the completed form to the EDD in the envelope provided. Submit your claim no earlier than nine
days after the first day your disability begins, but no later than 49 days after your disability begins. You
may lose benefits if your claim is late.
1. Complete ALL items in “PART A – CLAIMANT’S STATEMENT” and sign box A39. Errors or missing
information may cause your claim to be returned and delay payment. For box A13, the United States
Postal Service will not deliver mail to a private mail box unless it is preceded by the initials “PMB.”
2. Have your physician/practitioner complete and sign “Part B – PHYSICIAN/PRACTITIONER’S
CERTIFICATE.” Certification may be made by a licensed physician or practitioner authorized to certify
to a patient’s disability or serious health condition pursuant to CUIC, Section 2708. If you are under the
care of an accredited religious practitioner, obtain a “Claim for Disability Insurance Benefits - Religious
Practitioner’s Certificate,” DE 2502, by calling 1-800-480-3287 and ask your religious practitioner to
complete and sign it. Rubber stamp signatures are not accepted.
3. You should carefully decide the date you want your claim to begin because it may affect your benefit
amount. See “YOUR BENEFIT AMOUNTS” on page B for information.
4. If you have a work-related disability, complete questions A31 to A38. If your workers’ compensation
claim has been accepted, denied, or delayed, please include the status letter from the carrier.
5. Place the completed, signed form(s) in the envelope provided. A claim is complete when “PART A –
CLAIMANT’S STATEMENT” and “PART B – PHYSICIAN/PRACTITIONER’S CERTIFICATE” are received.
Claims are generally processed within 14 days.
6. Keep these instructions and information pages (A through D) for future reference.
The EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to
individuals with disabilities. Requests for services, aids, and/or alternate formats need to be made by calling
1-866-490-8879 (voice). TTY users, please call the California Relay Service at 711.
A
DE 2501 Rev. 80 (4-19) (INTERNET)
Page 1 of 11
Instruction & Information
Claim for Disability Insurance (DI) Benefits
The State Disability Insurance (SDI) program provides worker-funded benefits to eligible workers who have a
full or partial loss of wages due to disabilities that are not work related. The California Unemployment Insurance
Code (CUIC) states that a disability is any illness or injury, either physical or mental, that prevents you from
doing your regular or customary work. Disability also includes elective surgery and disabilities related to
pregnancy or childbirth.
Please read instruction and information pages (A through D) before completing the enclosed forms.
For faster processing, file your claim using SDI Online at www.edd.ca.gov. If you file online, do NOT mail this
form to the Employment Development Department (EDD).
DO NOT COMPLETE THIS FORM IF YOU ARE:
Insured by a Voluntary Plan. Ask your employer for the proper forms.
Filing for Non-Industrial Disability Insurance benefits. State government employees refer to your
personnel office.
If you cannot complete this form due to your disability, or if you are an authorized representative filing for benefits
on behalf of an incapacitated or deceased claimant, call 1-800-480-3287 or visit the EDD website to send an
online message using Ask EDD at https://askedd.edd.ca.gov.
HOW TO COMPLETE THIS FORM
Use black ink only.
Type or write clearly within the boxes provided.
Enter your Social Security number on all pages of the claim form including attachments.
Do not fax the form.
Mail the completed form to the EDD in the envelope provided. Submit your claim no earlier than nine
days after the first day your disability begins, but no later than 49 days after your disability begins. You
may lose benefits if your claim is late.
1. Complete ALL items in “PART A – CLAIMANT’S STATEMENT” and sign box A39. Errors or missing
information may cause your claim to be returned and delay payment. For box A13, the United States
Postal Service will not deliver mail to a private mail box unless it is preceded by the initials “PMB.”
2. Have your physician/practitioner complete and sign “Part B – PHYSICIAN/PRACTITIONER’S
CERTIFICATE.” Certification may be made by a licensed physician or practitioner authorized to certify
to a patient’s disability or serious health condition pursuant to CUIC, Section 2708. If you are under the
care of an accredited religious practitioner, obtain a “Claim for Disability Insurance Benefits - Religious
Practitioner’s Certificate,” DE 2502, by calling 1-800-480-3287 and ask your religious practitioner to
complete and sign it. Rubber stamp signatures are not accepted.
3. You should carefully decide the date you want your claim to begin because it may affect your benefit
amount. See “YOUR BENEFIT AMOUNTS” on page B for information.
4. If you have a work-related disability, complete questions A31 to A38. If your workers’ compensation
claim has been accepted, denied, or delayed, please include the status letter from the carrier.
5. Place the completed, signed form(s) in the envelope provided. A claim is complete when “PART A –
CLAIMANT’S STATEMENT” and “PART B – PHYSICIAN/PRACTITIONER’S CERTIFICATE” are received.
Claims are generally processed within 14 days.
6. Keep these instructions and information pages (A through D) for future reference.
The EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to
individuals with disabilities. Requests for services, aids, and/or alternate formats need to be made by calling
1-866-490-8879 (voice). TTY users, please call the California Relay Service at 711.
A
DE 2501 Rev. 80 (4-19) (INTERNET)
Page 1 of 11
Instruction & Information
BASIC ELIGIBILITY. DI benefits can be paid only after you meet all of
YOUR RIGHTS. Information about your claim will be kept
the following requirements:
confidential, except for the purposes allowed by law. California
Civil Code, section 1798.34, gives you the right to inspect any
You must be unable to do your regular or customary work for at
personal records maintained about you by the EDD. Section 1798.35
least eight consecutive days.
permits you to request that the record be corrected if you believe
You must be employed or actively looking for work at the time
it is not accurate, relevant, timely, or complete. Certain types of
you become disabled.
information that would generally be considered personal are exempt
You must have lost wages because of your disability or, if
from disclosure to you: medical or psychological records where
unemployed, have been actively looking for work.
knowledge of the contents might be harmful to the subject (Civil Code,
You must have earned at least $300 in wages from which SDI
section 1798.40); records of active criminal, civil, or administrative
deductions were withheld during your established base period
investigations (Civil Code, section 1798.40). If you are denied access
(see “YOUR BENEFIT AMOUNTS” in the next column).
to records which you believe you have a right to inspect or if your
You must be under the care and treatment of a licensed physician/
request to amend your records is refused, you may file an appeal with
practitioner or accredited religious practitioner during the first
the SDI office. You may request a copy of your file by calling SDI at
eight days of your disability. (The beginning date of a claim can
1-800-480-3287.
be adjusted to meet this requirement.) You must remain under
You also have the right to appeal any disqualification, overpayment, or
care and treatment to continue receiving benefits.
penalty. Specific instructions on how to appeal will be provided on any
You must complete and submit a claim form within 49 days of
appealable document you receive. If you file an appeal and you remain
the date you became disabled or you may lose benefits.
disabled, you must continue to complete and return continued claim
Your physician/practitioner must complete the medical
certifications.
certification of your disability. A licensed midwife or nurse-
midwife may complete the medical certification for disabilities
YOUR BENEFIT AMOUNTS. Your claim begins on the date your
related to normal pregnancy or childbirth. If you are under
disability began. SDI calculates your weekly benefit amount using
the care of a religious practitioner, request a “Practitioner’s
your base period. The date your disability began determines your base
Certificate,” DE 2502, from the SDI office. Certification by a
period, unless the claim effective date is adjusted by SDI. If you want
religious practitioner is acceptable only if the practitioner has
your claim to begin later so that you will have a different base period,
been accredited by the EDD.
please call SDI at 1-800-480-3287 before you file your claim.
We may require an independent medical examination to determine
This base period covers 12 months and is divided into four consecutive
your initial or continuing eligibility.
quarters. Your base period includes wages subject to SDI tax which you
were paid approximately 5 to 17 months before your disability claim
INELIGIBILITY. You may apply for benefits even if you are not sure you
begins. Your base period does not include wages being paid at the time
are eligible. If you are found to be ineligible for all or part of a period
claimed, you will be notified of the ineligible period and the reason.
the disability begins. For a disability claim to be valid, you must have
You may not be eligible for DI benefits if you:
at least $300 in wages in the base period. Using the following, you
may determine the base period for your claim.
are claiming or receiving Unemployment Insurance or Paid
If your claim begins in January, February, or March, your base
Family Leave benefits.
period is the 12 months ending last September 30.
became disabled while committing a crime resulting in a felony
conviction.
If your claim begins in April, May, or June, your base period is
are receiving Workers’ Compensation benefits at a weekly rate
the 12 months ending last December 31.
equal to or greater than the SDI rate.
If your claim begins in July, August, or September, your base
are in jail or prison because you were convicted of a crime.
period is the 12 months ending last March 31.
are a resident in an alcoholic recovery home or drug-free
If your claim begins in October, November, or December, your
residential facility that is not both licensed and certified by the
base period is the 12 months ending last June 30.
state in which the facility is located.
The quarter of your base period in which you were paid the highest
fail to submit to an independent medical examination when
wages determines your weekly benefit amount. You may not change
requested to do so.
the beginning date of your claim or adjust your base period after you
FRAUD. Under sections 2101, 2116, and 2122 of the California
have established a valid claim.
Unemployment Insurance Code, it is a violation to willfully make a
Your daily benefit amount is your weekly benefit amount divided by
false statement or knowingly conceal a material fact in order to
seven. Your maximum benefit amount is 52 times your weekly benefit
obtain the payment of any benefits, such violation being punishable
amount or the total wages subject to SDI tax paid in your base period,
by imprisonment and/or by a fine not exceeding $20,000 or both. To
whichever is less. Exceptions are as follows:
detect and discourage fraud, SDI continually monitors claim payments,
vigorously investigates suspicious activity, and will seek restitution
For employers and self-employed individuals who elect
and conviction through prosecution.
SDI coverage, the maximum benefit amount is 39 times the
weekly rate.
YOUR RESPONSIBILITIES.
For residents in a state licensed and certified alcoholic recovery
File your claim and other forms completely, accurately, and in a
home or drug-free residential facility, the maximum payable
timely manner. If a form is late, attach a written explanation of
period is 90 days. (However, disabilities related to or caused
the reason(s) to the form.
by acute or chronic alcoholism or drug abuse which are being
Thoroughly read the instructions on this and all other forms your
medically treated do not have this limitation.)
receive from SDI. If you are not sure what is required, contact
the SDI office.
Contact the SDI office to inquire and provide additional information
Report to SDI in writing, electronically, or by telephone any:
if your situation fits any of these circumstances: If you do not have
sufficient base period wages and you remain disabled, you may be able
-
change of address or telephone number.
to establish a valid claim by using a later beginning date. If you do not
-
return to part-time or full-time work.
have enough base period wages and you were actively seeking work
-
recovery from your disability.
quarter of the base period, you may be
-
income you receive.
for 60 days or more in any
able to substitute wages paid in prior quarters. Additionally, you may
Keep an appointment for an independent medical examination, if
be entitled to substitute wages paid in prior quarters either to make
requested.
your claim valid or to increase your benefit amount if during your
Include your name and Social Security number or Claim ID
base period you were in the U.S. military service, received Workers’
number on all correspondence.
Compensation benefits, or did not work because of a labor dispute.
B
DE 2501 Rev. 80 (4-19) (INTERNET)
Page 2 of 11
Instruction & Information
HOW BENEFITS ARE PAID. When your completed “PART
DISQUALIFICATION. All available information will be considered
A – CLAIMANT’S STATEMENT” and “PART B – PHYSICIAN/
before paying or disqualifying your claim. Benefits will be
paid only for the days to which you are entitled. If payment of
PRACTIONER’S CERTIFICATE” are received the SDI office
benefits is denied or reduced, you will be issued a “Notice of
will notify you by mail of your weekly and maximum benefit
Determination,” DE 2517, stating the reason for the disqualification
amounts and may request additional information if needed to
and the time period.
determine your eligibility. If you meet all requirements, the SDI
If you deliberately report incorrect information or if you willfully
program will issue a secure EDD Debit Card and electronic
omit or withhold information, false statement disqualifications of
benefit payments which can be accessed using the debit card.
up to 92 days are assessed. This may apply if you accept disability
The majority of claims are processed and payments issued within
benefit payments you know include days for which you should
14 days of receipt of both the claimant’s and the physician/
not be paid, such as days after you returned to work. In addition,
practitioner’s portions of the claim. The first seven days of your
any resulting overpayment will be increased by a 30 percent
claim is a non-payable waiting period.
penalty assessment.
If you are eligible for further benefits, either additional payments
SPECIAL CIRCUMSTANCES.
will be sent automatically or a continued claim certification form for
Work-related Disability. If you have suffered a work-related injury
the next period will be enclosed. Usually the certification periods
or illness, report it to your employer and have your physician/
are for two weeks; however, the period will vary under certain
practitioner submit a report to your employer’s Workers’
circumstances. You will be paid 1/7 of your weekly benefit amount
Compensation insurance carrier. If the Workers’ Compensation
for each calendar day you are eligible and disabled unless benefits
insurance carrier delays or refuses payments, SDI may pay you
are reduced for some reason. (See “BENEFIT REDUCTIONS”
benefits while your case is pending. However, SDI will pay
below.) If you receive DI benefits in place of Unemployment
benefits only for the period you are disabled and will file a lien
Insurance or Paid Family Leave benefits, the amounts paid will
to recover benefits paid. NOTE: SDI and Workers’ Compensation
be reported to the Internal Revenue Service. Contact the Internal
are two separate programs. You cannot legally be paid full
Revenue Service for more specific tax information.
benefits from both programs for the same period. However, if
BENEFIT REDUCTIONS. Under certain circumstances, you may
your Workers’ Compensation benefit rate is less than your SDI
not be eligible for a period of your claim or you may be entitled
rate, SDI may pay you the difference between the two rates. For
only to partial benefits. SDI will determine whether or not benefits
Workers’ Compensation information and assistance, call your local
must be reduced. The types of income shown in the following list
Workers’ Compensation Appeals Board office. You will find their
should be reported to SDI even though they may not always affect
listing in the State government pages of your telephone book under
your benefits. Failure to report your income could result in an
California, State of; Industrial Relations Department; Workers’
Compensation Appeals Board.
overpayment, penalties, and a false statement disqualification.
Pregnancy. As with any medical condition, the disability period
Sick leave pay
begins with the first day you are unable to do your regular
Self-employment income
or customary work. DI benefits will be paid for the period of
Military pay
time supported by your physician/practitioner’s certification.
Commissions
Pregnancy-related disability claims should NOT be submitted until
Wages, including modified duty wages
after the eighth day following the date your physician/practitioner
Residuals
certifies you are disabled.
Part-time work income
Bonding with a New Child. Contact the EDD’s Paid Family Leave
Bonuses
program at 1-877-238-4373. With the final DI benefit payment
issued to a new mother, a transition bonding claim form, “Claim
Workers’ Compensation benefits
for Paid Family Leave (PFL) Benefits – New Mother,” DE 2501FP,
Insurance settlements
will be sent automatically by mail or electronically to your online
Holiday pay
State Disability Insurance Online Service account if established.
In addition, your benefits may be reduced because of a prior
Child Support Questions. Contact the Department of Child
Unemployment Insurance, Paid Family Leave, or DI overpayment
Support Services at 1-866-249-0773.
or for delinquent court-ordered support payments.
Spousal or Parental Support Questions. Contact the District
BENEFIT INTERRUPTION and TERMINATION. A “Notice of
Attorney’s office administering the court order.
Final Payment,” DE 2525XX, will be issued when records show
Family Care. If a family member must stop work to care for you,
you have:
or if you stop work to care for a seriously ill family member,
been paid to your physician/practitioner’s estimated date
please visit www.edd.ca.gov or contact the EDD’s Paid Family
of recovery. If you are still disabled, ask your physician/
Leave program at 1-877-238-4373 for more information.
practitioner to complete and return the “Physician/
Long-term or Permanent Disability. If you expect your disability
Practitioner’s Supplementary Certificate,” DE 2525XXA,
to be long-term or permanent, contact the Social Security
(enclosed with the Notice of Final Payment).
Administration well before you exhaust your DI benefits. For
recovered or returned to your work. If you return to work and
information, call the Social Security Administration toll-free at
become disabled again, immediately submit a new claim form
1-800-772-1213.
and report the date s you worked.
Rehabilitation. If you have a disability which prevents you from
OVERPAYMENT. An overpayment results when you receive DI
getting or keeping a job, the Department of Rehabilitation may
benefits you were not entitled to receive. Once SDI determines
be able to assist you with vocational training, education, career
that you were overpaid, the SDI office will contact you to explain
opportunities, independent living, and use of assistive technology.
the reason for your overpayment. It is important that you complete
Job Training. Contact a One-Stop Career Center (1-877-872-5627
and return all information requests, as there are some instances
or www.servicelocator.org) for services available in your area.
when an overpayment can be waived. If it is determined that
Seeking Work. Contact the EDD for information and assistance
you were overpaid and the overpayment cannot be waived, you
concerning employment opportunities and Unemployment
must repay this money. Benefits issued after an overpayment is
Insurance benefits.
established may be reduced by 25 to 100 percent to collect your
overpayment. You will receive a “Notice of Overpayment Offset,”
Death of Claimant. If a person receiving DI benefits dies, an heir
or legal representative should report the death to SDI. Benefits are
DE 826, if a reduction is taken for either a DI, Paid Family Leave,
payable through date of death.
or Unemployment Insurance overpayment.
C
DE 2501 Rev. 80 (4-19) (INTERNET)
Page 3 of 11
Instruction & Information
FEDERAL PRIVACY ACT. The EDD requires disclosure of Social Security numbers 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.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT. Federal law requires that we obtain a separate authorization and
signature that permits your physician/practitioner to provide medical information regarding your claim. The EDD collects medical and
health information in accordance with Code of Federal Regulations, Title 45, Part 164.
INFORMATION COLLECTION AND ACCESS. State law requires the following information to be provided when collecting information
from individuals:
Agency Name:
Title of Official Responsible for Information Maintenance:
Employment Development Department (EDD)
Manager, EDD State Disability Insurance Office
Local Contact Person:
Contact Information:
Manager, EDD State Disability Insurance Office
You may contact State Disability Insurance by calling 1-800-480-3287. A list of
State Disability Insurance local office locations can be found on the Internet at
www.edd.ca.gov/disability/Contact_DI.htm. The address and phone number of
State Disability Insurance will also 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 3272.
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 or 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 Disability Insurance benefits.
To be summarized and published in statistical form for the use and information of government agencies and the public.
(Your name and identification will not appear in publications.)
To be used to locate persons who are being sought for failure to provide child, spousal, or other court-ordered 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 State 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: (1) Information may be revealed to the extent
necessary for the administration of public social services, to the Director of Social Services or his/her representatives, or to
the Director of Child Support Services or his/her representatives; (2) Claimant identity may be released to the Department
of Rehabilitation.
Information shall be disclosed to authorized agencies in accordance with California Unemployment Insurance Code, sections
1095 and 2714.
D
DE 2501 Rev. 80 (4-19) (INTERNET)
Page 4 of 11
Instruction & Information
Claim for Disability Insurance (DI) Benefits
250104191
Health Insurance Portability and Accountability Act (HIPAA) Authorization
Claimant Social Security Number
Claimant Name
(First)
(MI)
(Last)
I authorize
(Person/Organization providing the information) to furnish and disclose all my health
information and to allow inspection of and provide copies of any medical, vocational
rehabilitation, and billing records concerning my disability for which this claim is filed
that are within their knowledge to the following employees of the California Employment
Development Department (EDD): Disability Insurance Branch examiners, their direct
supervisors/managers and any other EDD employee who may have a need to access
this information in order to process my claim and/or determine eligibility for State
Disability Insurance benefits.
I understand that EDD is not a health plan or health care provider, so the information
released to EDD may no longer be protected by federal privacy regulations.
(45 CFR Section 164.508(c)(2)(iii)). EDD may disclose information as authorized by
the California Unemployment Insurance Code.
I agree that photocopies of this authorization shall be as valid as the original.
I understand I have the right to revoke this authorization by sending written notification
stopping this authorization to EDD, DI Branch MIC 29, PO Box 826880, Sacramento,
CA 94280. The authorization will stop on the date my request is received. I understand
that the consequences for my revoking this authorization may result in denial of further
State Disability Insurance benefits.
I understand that, unless revoked by me in writing, this authorization is valid for fifteen
years from the date received by EDD or the effective date of the claim, whichever is
later. I understand that I may not revoke this authorization to avoid prosecution or to
prevent EDD‘s recovery of monies to which it is legally entitled.
I understand that I am signing this authorization voluntarily and that payment or
eligibility for my benefits will be affected if I do not sign this authorization. The
consequences for my refusal to sign this authorization may result in an incomplete
claim form that cannot be processed for payment of State Disability Insurance benefits.
I understand I have the right to receive a copy of this authorization.
Date Signed
Claimant Signature (Do Not Print)
M
D
D
Y
Y
Y
Y
M
CU
DE 2501 Rev. 80 (4-19) (INTERNET)
Page 5 of 11
DE 2501 Rev. 80 (4-19)
Page 1 of 7
Page of 11