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Sdi online is your fast convenient and secure way to submit your disability insurance di and paid family leave pfl claims and forms online.
California disability form for physician. 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 andor a fine not. Complete this form legibly in ink. Applicants current physical address.
Page 1 of 9. Medical certification for disability exceptions. Sdi online reduces claim processing time provides online confirmation of submitted forms decreases costs in paper and postage includes security safeguards to detect and manage fraud and abuse and.
To complete forms you may need to download and save them on the computer then open them with the no cost adobe reader. Use anapplication for replacement plates stickers and documents form reg 156 to request replacement of a lost stolen or damaged placard or plates. To order this form call 1 855 342 3645 tty users dial the california relay service at 711.
Form n 648 edition 072320. If your patients disability extends beyond the original period established on their initial claim or the most recent medical extension please complete and submit the physicianpractitioners supplementary certificate de 2525xx. Physicians practitioners how to order a claim form online.
Department of homeland security. The following information is needed in connection with the patients application for disability retirement benefits under the california public employees retirement law. This form must be completed by a physicianmedical specialist who specializes in your disabling condition.
Visit accessibility if you need reasonable accommodation or an alternative format to access information on our website. Claim forms may be ordered by calling 1 855 342 3645 tty users dial the california relay service at 711. Forms are available at no cost to you.
Uscis form n 648. To avoid stocking outdated forms order a six month supply or less. To order view andor print disability insurance di and paid family leave pfl forms and publications visit the online forms and publications page.
Illegible incomplete andor unsigned forms will be returned. Name of member first name middle initial last name social security number or calpers id. Physicians report on disability.
If your disability will extend beyond the original period established on your claim have your physicianpractitioner complete and submit the de 2525xx online using sdi online. The documents on this webpage are pdfs. To submit by us mail you must first order the form by calling 1 800 480 3287 or 1 866 658 8846 en espanol.
The de 2525xx can be submitted online by accessing sdi online. Physicianspractitioners forms and publications. 1615 0069 expires 12312021 start here type or print in black ink.
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