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• Family Medical Leave Act
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Forms and Publications - Medical Providers

Below you will find informational forms and publications that you might find beneficial.

Forms

• Claim for Disability Insurance (DI) Benefits
  • DE 2501 - Rev. 77 (3-06)
• Claim for Paid Family Leave (PFL) Benefits ( An original form must be submitted by claimants. It cannot be downloaded or reproduced.)
  
  • DE 2501F (12-03)
    To order a single claim form, please use Request a Claim Form for Paid Family Leave Benefits, or call 1-877-238-4373. For bulk orders, please use the Internet Order Form for EDD Forms and Publications. Deaf, speech impaired, and hard of hearing callers can contact PFL directly by Teletypewriter (TTY) 1-800-445-1312 (this number does not accept voice calls.)
  • DE 2501F (12-03) - Sample claim form
    An example of a properly completed Claim for Paid Family Leave (PFL) Benefits form for individuals claiming benefits to provide care.
    
    If you are a woman currently receiving SDI pregnancy-related benefits, it is not necessary to request a Claim for Paid Family Leave Benefits. You will automatically be sent a Claim for Paid Family Leave (PFL) Benefits - New Mother, DE 2501FP, when your pregnancy-related disability claim ends.
    
    If you have not received this form within 10 days after your disability claim ends please call 1-877-238-4373.
• Independent Medical Examination (IME) Panelist Application
  • DE 2546D - Rev. 3 (3-08)
• State of California Department of Finance PAYEE DATA RECORD
  • STD. 204 - (Rev. 6 -2003)

Publications

• The Medical Provider’s Guide to Disability Insurance
  • DE 2548 - Rev. 3 (5-07)
• The Medical Provider’s Guide to Paid Family Leave
  • DE 2548F (3-04)
• Disability Insurance Provisions (For Disabilities Beginning on or After January 1, 2003) - Bulk orders (25 or more) see Internet Order Form
  • DE 2515 - Rev. 56 (11-08) - English
  • DE 2515/S - Rev. 55 (12-07) - Spanish
• Paid Family Leave Program Brochure
  • DE 2511 - Rev. 5 (1-08) - English
  • DE 2511I - Rev. 4 (1-08) - English - Printer-friendly version
  • DE 2511/B - Rev. 5 (1-08) - Cambodian
  • DE 2511/C - Rev. 5 (1-08) - Chinese
  • DE 2511/K - Rev. 5 (1-08) - Korean
  • DE 2511/L - Rev. 5 (1-08) - Laotian
  • DE 2511/S - Rev. 5 (1-08) - Spanish
  • DE 2511I/S - Rev. 4 (1-08) - Spanish - Printer-friendly version
  • DE 2511/T - Rev. 5 (1-08) - Thai
  • DE 2511/V - Rev. 6 (1-08) - Vietnamese
• Disability Insurance (DI) and Paid Family Leave (PFL) Weekly Benefit Amounts
  • DE 2588 - Rev. 4 (1-08)
• Disability Insurance (DI) and Paid Family Leave (PFL) Weekly Benefit Amounts in Dollar Increments
  • DE 2589 - Rev. 1 (1-08)
• Fact Sheets
  • Disability Insurance Program - DE 8714C - Rev. 31 (6-08) - English
  • Disability Insurance Program - DE 8714C/S - Rev. 31 (6-08) - Spanish
  • Paid Family Leave - DE 8714CF - Rev. 8 (3-08) - English
  • Paid Family Leave - DE 8714CF/S/ - Rev. 8 (3-08) - Spanish

You can order forms and publications, download and print Disability Insurance forms and publications, Paid Family Leave forms, publications, and informational materials.

Claim forms may also be ordered by calling DI or PFL toll-free.