Licensed Health Professional Forms and Publications

Find Disability Insurance (DI) and Paid Family Leave (PFL) forms, publications, and other important documents specifically for physicians/practitioners. To learn how to submit forms, visit Certify and Manage Claims.

For more EDD forms and publications, visit Online Forms and Publications.

The documents on this website are PDFs. To complete forms, you may need to download and save them on the computer, then open them with the no-cost Adobe Reader.

Forms

• Claim for Disability Insurance (DI) Benefits (DE 2501) (sample claim form)
  • Fill out and submit Part B – Physician/Practitioner’s Certificate.
• Claim for Paid Family Leave Benefits (PFL) Benefits (DE 2501F) (sample claim form)
  • Fill out and submit Part D – Physician/Practitioner’s Certification.
• If you are an accredited religious practitioner, you can download and print these forms. Do not complete these forms if you are a licensed physician or practitioner.
  • For DI: Complete and sign the Claim for Disability Insurance Benefits-Religious Practitioner’s Certificate (DE 2502) in lieu of Part D – Physician/Practitioner’s Certificate of the Claim for Disability Insurance (DI) Benefits (DE 2501) before sending it to the EDD.
  • For PFL: Complete and sign the Practitioner’s Certification for Paid Family Leave (PFL) Benefits (DE 2502F) in lieu of Part D – Physician/Practitioner’s Certificate of the Claim for Disability Insurance (DI) Benefits (DE 2501) before sending it to the EDD.
• Request for Continued Benefits – Physician/Practitioner’s Supplementary Certificate (DE 2525XX)
  • Access this form by logging in to your Benefit Programs Online (BPO) account and selecting SDI Online. You can also complete this certification using the paper form that your patient will receive by mail with their final payment.
• Medical Examiner Information (DE 2546Y)

Publications