Part A - Claimant's Statement
The patient completes and signs Part A: identity, employers, occupation and job classification, why they stopped working, any continued pay, and whether they have filed or intend to file for workers' compensation. Online certification only works after the patient has filed Part A electronically and shared the receipt number. On paper, Part B must be submitted together with Part A, or the application is incomplete.
Part B - Physician or Practitioner's Certificate: B1 to B11
Enter the patient's Social Security number, your file number, the electronic receipt number if known (it starts with R), date of birth and name. Then give your license number, the state or country that issued it, license type, specialty, your name as shown on the license and your address. EDD asks for the full license number including letters and no spaces; county and government facilities use their facility or hospital license number.
B12 to B14: Care dates, disability start and release date
Record the dates the patient has been under your care for this problem, the visit interval, and whether you are still treating. B13 asks whether the patient has been unable to do their regular or customary work, the date disability began, and whether an accident or trauma caused it. B14 needs the date you released or expect to release the patient; 'unknown' or 'indefinite' is not acceptable, though a permanent-disability box is available.
B15 to B18: Pregnancy
For a current or recent pregnancy, give the estimated delivery date or the date the pregnancy ended and the delivery type. If you do not expect to release the patient before delivery, B17 asks how many postpartum days of disability you expect for a vaginal and for a cesarean delivery. B18 records complications causing maternal disability; EDD's FAQ says early pregnancy claims need a valid pregnancy-related diagnosis code.
B19 to B22: ICD codes, diagnosis, findings and treatment
B19 requires the ICD diagnosis codes for the disabling condition, primary first, with the ICD-9 or ICD-10 box checked. B20 requires a diagnosis or, if none is established, a detailed statement of symptoms. B21 asks for the nature, severity and extent of the incapacitating condition, including other disabling conditions, and B22 for the treatment or medication given. EDD weighs these against the patient's age, occupation and estimated recovery.
B23 to B32: Hospitalization, surgery, work-relatedness and disclosure
Give hospital admission and discharge dates, any date of death, whether another provider treated the patient first, and the date and type of surgery or procedure with ICD procedure or CPT codes. B29 asks whether regular work caused or aggravated the condition, B30 and B31 cover referral to an alcohol or drug recovery facility, and B32 asks whether disclosure would be medically or psychologically detrimental to the patient.
B33: Certification and signature
Sign under penalty of perjury that the patient cannot perform their regular or customary work because of the listed condition, that you examined or treated the patient, and that you are authorized to certify under Unemployment Insurance Code section 2708. EDD requires an original signature and does not accept rubber stamps. Add your phone number and the date signed; false certification with intent to defraud violates sections 2116 and 2122.