VIOLATING A LAW OR ORDINANCE? IF “YES,” INDICATE NAME OF FACILITY:_________________________________________________________________ YES

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  VIOLATING A LAW OR ORDINANCE? IF “YES,” INDICATE NAME OF FACILITY:_________________________________________________________________ YES
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  DE 2501 Rev. 75 (3-05)  (INTERNET) Page 1 of 4 CU   Claim for Disability Insurance Benefits – Claim Statement of Employee TYPE or PRINT with BLACK INK. 1. YOUR SOCIAL SECURITY NUMBER2. IF YOU HAVE EVER USED OTHER SOCIAL SECURITY NUMBERS, SHOW THOSE NUMBERS BELOW5. HAVE YOU WORKED ANY FULL OR PARTIAL   DAYS SINCE YOUR DISABILITY BEGAN?6. DATE YOU RECOVERED OR   RETURNED TO WORK ( IF ANY ) 3. DATE YOUR DISABILITY BEGAN4. LAST DATE YOU WORKED MM DD YY   MM DD YY   YES NOMM DD YY   7. GENDER8. YOUR LEGAL NAME9. YOUR DATE OF BIRTH   MALE FEMALEFIRST NAME MIDDLE NAME OR INITIAL LAST NAMEMM DD YY   10. OTHER NAMES, IF ANY, UNDER WHICH YOU HAVE WORKED11. LANGUAGE YOU PREFER TO USE   ___________________ ENGLISH ESPAÑOL OTHER 12. YOUR MAILING ADDRESS ( IF YOU WISH TO RECEIVE MAIL AT A PRIVATE MAIL BOX — NOT A US POSTAL SERVICE BOX — YOU MUST SHOW THE NUMBER IN THE “PMB#” SPACE .) NUMBER  / STREET  / P . O .  BOX  / APARTMENT OR SPACE # PMB # ( PRIVATE MAIL BOX #) CITYSTATECOUNTRY ( IF NOT UNITED STATES OF AMERICA ) ZIP CODE 13. YOUR AREA CODE AND TELEPHONE NUMBER 14. YOUR RESIDENCE ADDRESS, IF DIFFERENT FROM YOUR MAILING ADDRESS ( ) NUMBER  / STREET  / APARTMENT OR SPACE # CITYSTATECOUNTRY ( IF NOT UNITED STATES OF AMERICA ) ZIP CODE 15. WHY DID YOU STOP WORKING?16. YOUR LAST OR CURRENT EMPLOYER – IF YOUR LAST OR CURRENT EMPLOYMENT WAS SELF - EMPLOYMENT , ENTER “ SELF ” EMPLOYER ‘ S AREA CODE AND TELEPHONE NUMBER ( ) NAME OF EMPLOYERNUMBER  / STREET  / SUITE # CITYSTATECOUNTRY ( IF NOT UNITED STATES OF AMERICA ) ZIP CODE 17. YOUR REGULAR OCCUPATION18. IF YOUR EMPLOYER CONTINUED TO PAY YOU, INDICATE TYPE OF PAY  ________________ SICK VACATION OTHER 19. MAY WE DISCLOSE BENEFIT PAYMENT   INFORMATION TO YOUR EMPLOYER?   YES NO 20. SECOND EMPLOYER ( IF YOU HAVE MORE THAN ONE EMPLOYER ) EMPLOYER ‘ S AREA CODE AND TELEPHONE NUMBER ( ) NAME OF EMPLOYERNUMBER  / STREET  / SUITE # CITYSTATECOUNTRY ( IF NOT UNITED STATES OF AMERICA ) ZIP CODE 21. AT ANY TIME DURING YOUR DISABILITY WERE YOU IN THE CUSTODY OF LAW ENFORCEMENT AUTHORITIES BECAUSE YOU WERE CONVICTED OFVIOLATING A LAW OR ORDINANCE?  IF “ YES ,” INDICATE NAME OF F ACILITY :_________________________________________________________________  YES NO 556-82-6022   DeniseLCarson01/22/19  7433 Hesperia AveResedaCa91335310593-3904husband fell ill310571-4127John C. Schureman PhD, Inc12381 Wilshire Blvd. #205Los AngelesCa90025  DE 2501 Rev. 75 (3-05)  (INTERNET) Page 2 of 4 CU Claim Statement of Employee - continued 22. PLEASE RE-ENTER YOUR SOCIAL SECURITY NUMBER....................................   ................................................   23. IF YOU ARE A RESIDENT OF AN ALCOHOLIC RECOVERY HOME OR A DRUG-FREE RESIDENTIAL FACILITY, SHOW THE NAME, TELEPHONE NUMBER, AND ADDRESS NAME OF FACILITYFACILITY AREA CODE AND TELEPHONE NUMBER ( ) ADDRESS OF FACILITY ( NUMBER AND STREET  / CITY  / STATE  / ZIP CODE ) 24. WAS THIS DISABILITYCAUSED BY YOUR JOB?   YES   NO 25. HAVE YOU FILED OR DO YOU INTEND TO FILEFOR WORKERS’ COMPENSATION BENEFITS?   YES– COMPLETE ITEMS 26 THROUGH 32   NO– SKIP TO ITEMS 31 AND 32 26. DATE(S) OF INJURY SHOWN ON YOUR WORKERS’ COMPENSATION CLAIM 27. WORKERS’ COMPENSATION INSURANCE COMPANY COMPANY NAMECOMPANY AREA CODE AND TELEPHONE NUMBER   NUMBER  / STREET  / SUITE # CITYSTATEZIP CODE 28. WORKERS’ COMPENSATION ADJUSTER ADJUSTER NAMEADJUSTER AREA CODE AND TELEPHONE NUMBER   29. EMPLOYER SHOWN ON YOUR WORKERS’ COMPENSATION CLAIM EMPLOYER NAMEEMPLOYER AREA CODE AND TELEPHONE NUMBER   30. YOUR ATTORNEY (IF ANY) FOR YOUR WORKERS’ COMPENSATION CASE ATTORNEY NAMEATTORNEY AREA CODE AND TELEPHONE NUMBER   NUMBER  / STREET  / SUITE # CITYSTATEZIP CODE PLEASE REVIEW, SIGN, AND DATE BOTH NO. 31 AND NO. 32. 31. Health Insurance Portability and Accountability Act Authorization. I authorize any physician, practitioner, hospital, vocational rehabilitation counselor, or workers’compensation insurance carrier to furnish and disclose to employees of California Employment Development Department (EDD) all facts concerning my disability that arewithin their knowledge and to allow inspection of and provide copies of any medical, vocational rehabilitation, and billing records concerning my disability that are undertheir control. I understand that EDD may disclose information as authorized by the California Unemployment Insurance Code and that such redisclosed information mayno longer be protected by this rule. I agree that photocopies of this authorization shall be as valid as the srcinal. I understand that, unless revoked by me in writing, thisauthorization is valid for fifteen years from the date received by EDD or the effective date of the claim, whichever is later. I understand that I may not revoke thisauthorization to avoid prosecution or to prevent EDD’s recovery of monies to which it is legally entitled. Claimant’s Signature (DO NOT PRINT)Date Signed 32. Declaration and Signature. By my signature on this claim statement, I claim benefits and certify that for the period covered by this claim I was unemployed and disabled.I understand that willfully making a false statement or concealing a material fact in order to obtain payment of benefits is a violation of California law and that suchviolation is punishable by imprisonment or fine or both. I declare under penalty of perjury that the foregoing statement, including any accompanying statements, is to thebest of my knowledge and belief true, correct, and complete. By my signature on this claim statement, I authorize the California Department of Industrial Relations andmy employer to furnish and disclose to State Disability Insurance all facts concerning my disability, wages or earnings, and benefit payments that are within theirknowledge. By my signature on this claim statement, I authorize release and use of information as stated in the “Information Collection and Access” portion of this form. Iagree that photocopies of this authorization shall be as valid as the srcinal, and I understand that authorizations contained in this claim statement are granted for a periodof fifteen years from the date of my signature or the effective date of the claim, whichever is later. Claimant’s Signature (DO NOT PRINT) Date SignedIf your signature is made by mark (X), it must be attested by two witnesses with their addresses 1 st  Witness Signature and Address2nd Witness Signature and Address 33. Personal Representative  signing on behalf of claimant must complete the following: I,______________________________________ , represent the claimant in thismatter as authorized by power of attorney (attach copy) Declaration of Individual Claiming Disability Insurance Benefits Due an Incapacitated or DeceasedClaimant, DE 2522 (see pg. A,#4) Personal Representative’s Signature (DO NOT PRINT)Date Signed 556-82-6022  DE 2501 Rev. 75 (3-05)  (INTERNET) Page 3 of 4 CU  Claim for Disability Insurance Benefits – Doctor’s Certificate TYPE or PRINT with BLACK INK. 34. PATIENT’S FILE NUMBER35. PATIENT’S SOCIAL SECURITY NO.36. PATIENT’S LAST NAME37. DOCTOR’S NAME AS SHOWN ON LICENSE38. DOCTOR’S TELEPHONE NUMBER ( ) 39. DOCTOR’S STATE LICENSE NO. 40. DOCTOR’S ADDRESS –   NUMBER AND STREET , CITY , STATE , COUNTRY ( IF NOT USA ), ZIP CODE . POST OFFICE BOX NUMBER IS NOT ACCEPTED AS THE SOLE ADDRESS 41. THIS PATIENT HAS BEEN UNDER MY CARE AND TREATMENT FOR THIS MEDICAL PROBLEM  FROM _______/_______/________ TO _______/_______/________ AT INTERVALS OF DAILY WEEKLY MONTHLY AS NEEDED 42. AT ANY TIME DURING YOUR ATTENDANCE FOR THIS MEDICAL PROBLEM, HAS THEPATIENT BEEN INCAPABLE OF PERFORMING HIS/HER REGULAR   OR CUSTOMARY WORK?43. DATE YOU RELEASED OR ANTICIPATE RELEASINGPATIENT TO RETURN TO HIS/HER REGULAR / CUSTOMARY WORKNO – SKIP TO THE DOCTOR ’ SCERTIFICATION SECTION YES – ENTER DATE DISABILITY BEGAN :   _______/_______/_______(“ UNKNOWN ,” “ INDEFINITE ,” ETC ., NOT ACCEPTED .) _____/_____/_____ 44. ICD9   DISEASE CODE, PRIMARY ( REQUIRED UNLESS DIAGNOSIS NOT YET OBTAINED )   _________ .   _____ 45. ICD9   DISEASE CODE(S), SECONDARY   _________ .   _____, _________ .   _____, _________ .46. DIAGNOSIS ( REQUIRED ) – IF NO DIAGNOSIS HAS BEEN DETERMINED , ENTER OBJECTIVE FINDINGS OR A DETAILED STATEMENT OF SYMPTOMS 47. FINDINGS – STATE NATURE, SEVERITY, AND EXTENT OF THE INCAPACITATING DISEASE OR INJURY.   INCLUDE ANY OTHER DISABLING CONDITIONS48. TYPE OF TREATMENT / MEDICATION RENDERED TO PATIENT49. IF PATIENT WAS HOSPITALIZED, PROVIDE DATES OFENTRY AND DISCHARGE______/_____/_______ TO ______/_____/_______50. DATE AND TYPE OF SURGERY / PROCEDURE   PERFORMED OR TO BE PERFORMED   ______/_____/_______ICD9   PROCEDURE CODE(S)51. IF PATIENT IS NOW PREGNANT OR HAS BEEN PREGNANT, WHAT DATE DIDPREGNANCY TERMINATE OR WHAT DATE DO YOU EXPECT DELIVERY?52. IF PREGNANCY IS / WAS ABNORMAL, STATE THE ABNORMAL ANDINVOLUNTARY COMPLICATION CAUSING MATERNAL DISABILITY   _____/_____/_____ 53. BASED ON YOUR EXAMINATION OF PATIENT, IS THISDISABILITY THE RESULT OF “OCCUPATION,” EITHERAS AN “INDUSTRIAL ACCIDENT” OR AS AN“OCCUPATIONAL DISEASE”? ( INCLUDE SITUATIONSWHERE PATIENT ’ S OCCUPATION HAS AGGRAVATED PRE - EXISTING CONDITIONS .)   YES NO54. ARE YOU COMPLETING THIS FORM FOR THE SOLEPURPOSE OF REFERRAL / RECOMMENDATION TO ANALCOHOLIC RECOVERY HOME OR DRUG-FREERESIDENTIAL FACILITY AS INDICATED BY THE PATIENTIN QUESTION 23?   YES NO55. WOULD DISCLOSURE OFTHIS INFORMATION TOYOUR PATIENT BEMEDICALLY ORPSYCHOLOGICALLYDETRIMENTAL?   YES NO Doctor’s Certification and Signature (REQUIRED) : Having considered the patient’s regular or customary work, I certify under penalty of perjurythat, based on my examination, this Doctor’s Certificate truly describes the patient’s disability (if any) and the estimated duration thereof.I further certify that I am alicensed to practice in the State of.( TYPE OF DOCTOR )( SPECIALTY , IF ANY ) ORIGINAL SIGNATURE OF ATTENDING DOCTOR – RUBBER STAMP IS NOT ACCEPTABLEDATE SIGNED 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 medicalcondition of any person in order to obtain disability insurance benefits, whether for the maker or for any other person, and is punishable by imprisonment and/or a fine notexceeding $20,000. Section 1143 requires additional administrative penalties. 556-82-6022  DE 2501 Rev. 75 (3-05)  (INTERNET) Page 4 of 4 CU Health Insurance Portability andAccountability Act (HIPAA) AuthorizationState Disability Insurance Claimant:1. Complete, sign, and date thisform. 2. Take the completed signed form toyour doctor. CLAIMANT ’ S NAME ( FIRST , MIDDLE INITIAL , LAST ) CLAIMANT ’ S SOCIAL SECURITY NUMBER I authorize any physician, practitioner, hospital, vocational rehabilitation counselor, orworkers’ compensation insurance carrier to furnish and disclose to employees ofCalifornia Employment Development Department (EDD) all facts concerning mydisability that are within their knowledge and to allow inspection of and provide copiesof any medical, vocational rehabilitation, and billing records concerning my disabilitythat are under their control.I understand that EDD may disclose information as authorized by the CaliforniaUnemployment Insurance Code and that such redisclosed information may no longerbe protected by this rule.I agree that photocopies of this authorization shall be as valid as the srcinal.I understand that, unless revoked by me in writing, this authorization is valid forfifteen years from the date received by EDD or the effective date of the claim,whichever is later.I understand that I may not revoke this authorization to avoid prosecution or toprevent EDD’s recovery of monies to which it is legally entitled. CLAIMANT ’ S SIGNATURE (DO NOT PRINT) DATE SIGNED DeniseLCarson556-82-6022
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