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California DE 2501F Part D: PFL Care Certification

When a California worker claims Paid Family Leave to care for a seriously ill family member, the care recipient's licensed clinician must certify the serious health condition and the need for care. Part D records the diagnosis, ICD codes, when care started, when it should end and the hours of care needed per day. EDD processes the care claim only after this certification arrives, online or on paper.

Who completes it

The care recipient's licensed physician or practitioner completes and signs Part D. The caregiver (claimant) completes Part A, and the family member receiving care completes and signs Part C, which authorizes the clinician to share current health information with the caregiver and EDD.

How to fill it in

Part A - Statement of Claimant (Care, Bonding, or Military Assist Provider)

The caregiver completes and signs Part A with their identity, employment and leave details. If they file through SDI Online they receive a receipt number, which you need to find the claim when certifying online. On paper, a care claim is complete only when EDD receives Parts A, C and D together, so the caregiver should collect your Part D before mailing.

Part C - Statement of Family Member Receiving Care

The patient gives their date of birth, phone, legal name and address, and signs C6, authorizing you to disclose their current health information to the caregiver and EDD. The claimant may fill it in if the family member cannot, but it must be signed by the family member or by an authorized representative acting under parental right, power of attorney or court order (C7).

Part D - Physician/Practitioner's Certification: D1 to D5

Enter the claimant's (care provider's) Social Security number and name, then the patient's date of birth and name. D4 asks whether your patient requires care by the claimant; answering No sends you straight to D15 for your own details. The instructions ask for upper case in black ink, one character per box, and no special characters such as dashes, commas, periods or slashes.

D6 to D8: Diagnosis and ICD codes

Give the diagnosis or, if it is not yet determined, a detailed statement of symptoms, then the primary ICD code and any secondary ICD codes. EDD's guide for licensed health professionals lists the diagnosis and its corresponding ICD code among the items every PFL certification must include, and EDD reviews diagnoses and codes closely against the amount of care requested.

D9 to D13: Dates and hours of care

Enter the date the condition started, the first date the patient needed care, the date you expect the patient to recover (or check Never) and the date the patient will no longer need care by the claimant (or check Permanent). D13 asks approximately how many total hours per day the patient needs the claimant. A longer-than-normal period may prompt EDD to contact you or request an independent medical exam.

D14 to D20: Disclosure and practitioner details

D14 asks whether disclosing this certificate to your patient would be medically or psychologically detrimental. Then enter your license number, the state or country where you are licensed, your name, your address (a post office box alone is not acceptable), the type of physician or practitioner and any specialty. EDD verifies that the license is current and in good standing before accepting the certification.

D21: Certification and signature

Sign under penalty of perjury that the patient has a serious health condition and requires a care provider, that you performed a physical examination and/or treated the patient, and that you are authorized to certify under Unemployment Insurance Code section 2708. Use an original signature, since rubber stamps are not accepted, and add your phone number and the date signed.

Common mistakes

  • Completing Part D for a bonding or military assist claim; the form says not to, and those claims need no medical certification.
  • Writing 'unknown' or 'indefinite' instead of estimated dates for recovery and the end of care, which EDD lists among the causes of delayed claims.
  • Using a rubber stamp, address labels, correction tape or strikeouts on the paper form, which cause scanner errors and delays.
  • Listing only a post office box as the practitioner address in D18, which the form states is not acceptable.
  • Mailing a paper Part D after already certifying through SDI Online, since duplicate certifications slow processing.
  • Using dashes, commas, periods or slashes in the boxes; the Part D instructions call for upper case, black ink and no special characters.

Submitting and payment

How to submit it
Certify through SDI Online with the claimant's receipt number once the claimant has filed electronically, or complete Part D of the paper DE 2501F so it is submitted with Parts A and C. The certification is due within 41 days of the date family leave begins.
Who pays
EDD states that no law prohibits clinicians or their offices from charging patients for completing Paid Family Leave forms, and EDD pays for any independent medical examination it requests.

Good to know

  • Only care claims need Part D. Bonding and military assist claims require no medical certification, and Part D itself says not to complete it for those claims.
  • The care recipient must be the claimant's child, spouse, registered domestic partner, parent, parent-in-law, grandparent, grandchild or sibling, and PFL pays up to eight weeks of benefits within a 12-month period.
  • If care is still needed after the certified end date, EDD may send a PFL Supplemental Claim Certification (DE 2525XFA) for you to complete; extensions are due within 20 days.
  • Accredited religious practitioners certify on DE 2502F instead, and state employees in certain bargaining units file DE 8501F for Nonindustrial Disability Insurance Family Care Leave.

Get the official form

Download the current version from the source each time; forms change without notice.

Application for Paid Family Leave Benefits (Part D - Physician/Practitioner's Certification)

Official pagePDF

Get the note ready with Vero

This form is completed online with California Employment Development Department (EDD), State Disability Insurance, so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Sources for this guide

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who can certify a California Paid Family Leave care claim?

EDD's guide lists licensed medical or osteopathic physicians and surgeons, medical officers of U.S. government facilities, registrars of California county hospitals, chiropractors, podiatrists, optometrists, dentists and psychologists, plus nurse practitioners or physician assistants after examination and collaboration with a physician. Accredited religious practitioners certify on DE 2502F rather than Part D.

Does a California PFL bonding claim need a doctor's certification?

No. Bonding claims require a document proving the relationship, such as a birth certificate, but no medical certification. After a pregnancy disability claim ends, EDD sends the new mother a DE 2501FP application to move to a bonding claim. Part D is used only when a worker is caring for a seriously ill family member.

What counts as care on a DE 2501F certification?

EDD describes qualifying care as including medical help, eating, self-care, transportation, emotional support, planning future care and giving other caregivers relief, at home, in a hospital, hospice or residential facility. Question D13 asks approximately how many total hours per day the patient will need the claimant, with space for comments.

What is the deadline for DE 2501F Part D?

Certify as soon as possible and no later than 41 days after the caregiver's leave begins. EDD will not process the claim until it receives the certification. Paid Family Leave has no waiting period, but the caregiver must be unable to do their regular work for at least one day because of caregiving.