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EDD DE 8501F: NDI Family Care Leave Certification

Excluded California state employees in the Annual Leave Program use this claim for Nonindustrial Disability Insurance Family Care Leave to care for a seriously ill family member, bond with a new child, or attend to a family member's military deployment. For care claims, the care recipient's physician or practitioner completes Part E, certifying the serious health condition, when care is needed and the daily hours of care.

Who completes it

The care recipient's treating physician or practitioner completes Part E, which is not used for bonding claims; the employer fills Part A, the employee Part B, and the care recipient Part D. A recipient under an accredited religious practitioner needs DE 2502FF instead.

Submitting and payment

How to submit it
The claimant mails the completed form to EDD's NDI-FCL unit in the envelope provided. A care claim is complete only when Parts A, B, D and E are received, and is generally processed within 14 days.

Good to know

  • Part E asks whether the patient requires care by the claimant, the diagnosis or symptoms with ICD codes, the first date care is needed, expected recovery and approximate hours of care per day.
  • Sign Part E with an original signature: rubber stamps are not accepted, and the certification is made under penalty of perjury.
  • Covered care recipients are the employee's child, parent, spouse, registered domestic partner, grandparent, grandchild, sibling or parent-in-law.
  • Claims may be filed no earlier than the first day of family leave. The form is the state-employee counterpart of the PFL claim form DE 2501F.

Get the official form

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

Claim for Nonindustrial Disability Insurance - Family Care Leave (NDI-FCL) (Part E - Physician/Practitioner's Certification)

Official pagePDF

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.

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Frequently asked questions

Who completes Part E of the DE 8501F?

A licensed physician or practitioner authorized under California Unemployment Insurance Code section 2708 who is treating the care recipient. They certify under penalty of perjury that the patient has a serious health condition and requires a care provider, and give license number, state or country of licensure and specialty.

Is Part E needed for a DE 8501F bonding claim?

No. Part E is marked not to be completed for bonding. A bonding claim is complete with Parts A, B and C plus a supporting document, and a military assist claim uses Part F instead. Part E applies only to claims for caring for a seriously ill family member.