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Claim for Paid Family Leave (PFL) Care Benefits (DE 2501FC ...

DE 2501FC Rev. 3 (11-16) (INTERNET) Page 1 of 4 CU 0 BClaim for paid Family Leave 1B(PFL) Care Benefits 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. Read and sign the Care Recipient s Authorization for Disclosure of Personal-Health information on page 2. If the care recipient is physically or mentally unable to sign, call PFL at (1-877-238-4373) for instructions. Both pages may be mailed or sent electronically in SDI Online as attachments.

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

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  Family, California, Leave, Paid, California paid family leave

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  Report, Employee, Report of new employee

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DE 2320 Rev. 63 (4-18) (INTERNET) Page 3 of 19 If you served in the military in the last 18 months, you will need to provide information from your DD214 Member copy 4. If you worked for the federal government during the last 18 months, you

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