Paid Family Leave

STEP-BY-STEP GUIDE TO APPLYING FOR PAID FAMILY LEAVE (PFL)
 EMPLOYMENT DEVELOPMENT DEPARTMENT

PAID FAMILY LEAVE (PFL) STEP-BY-STEP GUIDE TO APPLYING
EMPLOYMENT DEVELOPMENT DEPARTMENT

This guide is designed to provide general information on the topics presented. It is provided with the understanding that City of Hope is not engaged in rendering any legal or professional advice by its publication or distribution. City of Hope has no relationship or affiliation with the agencies listed. City of Hope is not responsible for the accuracy of the information obtained from third party websites or materials, or for the availability of such third-party content. City of Hope does not control, endorse, sponsor, recommend or otherwise accept responsibility for such third-party content. Use of any third-party content is at the user’s own risk.

Eligibility requirements and application process for benefits on this guide are mirrored from the California Employment Development Department’s (EDD) latest publications.
City of Hope is not responsible for and does not participate in EDD’s claims decision making.
City of Hope’s role is specific to Physician/Practitioners Certification. All forms go to Medical Records or the health care team for completion.
For questions about specific claims or Paid Family Leave processes, call EDD Paid Family Leave Program at (877) 238-4373 or visit edd.ca.gov/Disability/PFL_Claim_Process.htm

WHAT IS PAID FAMILY LEAVE?

Paid Family Leave (PFL) is a financial benefit through the State of California that provides up to six weeks of partial pay to employees who take time off from work to care for a seriously ill family member (child, parent, parent-in-law, grandparent, grandchild, sibling, spouse, or registered domestic partner).

PFL gives you up to 60-75% of your lost wages for up to eight weeks of benefits in a 12-month period (as of 7/1/2020). It will not give you job protection or return-to-work rights. Your job may be protected through other federal or state laws such as the Family and Medical Leave Act. Visit dol.gov/whd/fmla for more information.

ELIGIBILITY REQUIREMENTS

You must:
• Be unable to do your regular work because you are taking care of a seriously ill family member (known as the “care recipient”).
• Be employed or actively looking for work at the time your family leave begins.
• If working, have lost wages because you were caring for a seriously ill family member.
• Have earned at least $300 from which state Disability Insurance deductions were withheld during a previous period (look for“CASDI” on your paystubs).
• Complete a claim form within 41 days after the first day your family leave begins or you may lose benefits. If you’re caring for a seriously ill family member, you must meet the following additional requirements:
• The care recipient must be your child, parent, spouse, registered domestic partner, grandparent, grandchild, sibling or parent-in-law.
• The care recipient (seriously ill family member) must be under the continuing treatment or supervision of a licensed doctor or health care provider while you are receiving benefits.

Important: Gather Required Information Before Applying

You must provide the following information to file a Paid Family Leave claim:
• First and last name
• Social Security number
• Most current employer’s business name, phone number, and mailing address (as stated on your-2 or paystub)

Provide the information below ONLY if it applies to you:
• Any wages you received or expect to receive from your employer (sick leave, paid time off, vacation pay, annual leave and wages earned after you stopped working)
• Any workers’ compensation claim information

You Can Apply Two Ways: Online and in Paper Form

There are two ways to file for PFL — online or sending a paper form by mail. Watch video instructions on how to apply for PFL and complete the online application at edd.ca.gov/Disability/SDI_Online_Tutorials.htm.

CLICK ON:

“How to File a Paid Family Leave Claim using SDI Online” (English) (YouTube)
“How to File a Paid Family Leave Claim using SDI Online” (Spanish) (YouTube)
“How to File a Paid Family Leave Claim by Mail” (English) (YouTube)
“How to File a Paid Family Leave Claim by Mail” (Spanish) (YouTube)


Apply for a PFL Online

The fastest and easiest way to file a PFL claim is online through the Employment Development Department (EDD)’s State Disability Insurance (SDI Online) website.


STEP 1: Create an SDI online account at edd.ca.gov/Benefit_Programs_Online.htm.
You may have to “Register” as a first time user. If you have applied for benefits before (including Unemployment, State Disability Insurance or PFL) you may already have an existing account.

STEP 2: Log in to your SDI account and select “File a New Claim.”
STEP 3: Select “Paid Family Leave Care” and follow the steps to fill out the form.
❑ Select ”Submit” to send the completed SDI Online Part A — Statement of Claimant to the EDD.

STEP 4: On the confirmation page, be sure to write down the form receipt number.
(Selecting the form receipt number link will automatically open a PDF printer-friendly version). Please give the receipt number to the care recipient’s (patient’s) City of Hope physician or care practitioner.

STEP 5: Additional Documents Required
You must also provide these documents to complete the claim. Note: It may be necessary to send some documents via U.S. mail.
On the confirmation page, download and print these forms, and turn in with confirmation page to Medical Records [Duarte] or your health care team at the Community Practice Sites.
❑ Care Recipient’s Authorization for Disclosure of Personal Health Information signed by the person’s care recipient or their authorized representative
❑ Part C — Statement of Care Recipient signed by the person’s care recipient or their authorized representative
Part D — Physician/Practitioner’s Certification of the Claim for Paid Family Leave Benefits form (DE 2501F) completed and signed by the care recipient’s doctor or
health care provider


Your full name

Form receipt number:



Care recipient’s full name

Medical record number (MRN) of
care recipient

Care recipient’s date of birth

Care recipient’s Social Security number

Physician name that paperwork should be sent to
Duarte Campus patients: Request can be submitted in person to Medical Records office (near registration desk in Main Medical building), by email to DL-HIMSMedicalForms@coh.org, or via FAX at 626-218-0677. City of Hope’s Medical Records will forward the information to the City of Hope physician for completion.
Community Practice Site patients: submit to your health care team at the City of Hope location you visit.
Include these with your confirmation page:Please allow up to 10 business days for the request to be processed. You will receive a confirmation email from PFL when the physician certification is completed.
If you have not received anything from PFL within 10 days, or if you have any questions,
you may call the EDD Paid Family Leave Program at 877-238-4373.



You will need to provide this number to your health care provider for their portion of the claim.
❑ Submit the confirmation page to your health care team at City of Hope.

Include these with your confirmation page:
❑ Form receipt number: _______________________ ❑ Care recipient’s full name
❑ Medical record number of care recipient
❑ Care recipient’s date of birth
❑ Last four digits of care recipient’s Social Security number
❑ Physician name that paperwork should be sent to

Please allow up to 10 business days for the request to be processed. You will receive a confirmation email from PFL when the physician certification is completed.

STEP 4: Additional Documents Required
You must also provide these documents to complete the claim. Note: It may be necessary to send some documents via U.S. mail.
On the confirmation page, you can download these forms:
Care Recipient’s Authorization for Disclosure of Personal Health Information
Part C — Statement of Care Recipient
signed by the person’s care recipient or their authorized representative
❑ Part D — Physician/Practitioner’s Certification of the Claim for Paid Family Leave Benefits form (DE 2501F) completed and signed by the care recipient’s doctor or health care provider.
If you have not received anything from PFL within 10 days, or if you have any questions, you may call the EDD Paid Family Leave Program at 877-238-4373.

IMPORTANT – Be reminded:
❑ It is your responsibility to have the doctor or health care provider to complete and sign the form and submit it to the EDD within 41 days from the date your family leave begins or you may lose benefits.
❑ Your claim will not be processed until all the required sections (as explained in previous steps) of the application are received. The EDD will contact you with the status of your claim. Be sure to check your inbox on SDI Online for notifications from EDD.
❑ Your employer will be notified that you have submitted a PFL claim. Medical information is confidential and will not be shared with your employer.
For more information, visit After You File for PFL: Claim Processing
at edd.ca.gov/Disability/Claim_Processing_for_PFL.htm.

Apply for a PFL by Mail

To file a PFL claim by mail, complete and submit a Claim for Paid Family Leave Benefits form (DE 2501F).

STEP 1: Obtain a Paper Claim Form
There are a few different ways to obtain a paper Claim for Paid Family Leave Benefits form (DE 2501F):
❑ Visit Online Forms and Publications at forms.edd.ca.gov/forms and order
Form DE 2501F. A form will be mailed to you.
❑ You may be able to obtain the form from your doctor or health care provider’s office or the human resources department at your employer.
❑ Visit an SDI office. Find office locations at edd.ca.gov/Disability/Contact_SDI.htm.
❑ Call the EDD Paid Family Leave Program at 877-238-4373.

STEP 2: Complete Claim for Benefits Form (DE2501F)
❑ Fill out Part A — Claimant’s Statement (page 1), of the DE 2501F form. Be sure to write clearly in the spaces provided, use black ink only and sign the form.
❑ Ask the care recipient or authorized representative to complete and sign the Care Recipient’s Authorization for Disclosure of Personal Health Information and Part C — Statement of Care Recipient of the form.
❑ You also need Part D — Physician/Practitioner’s Certification of the Claim for Paid Family Leave Benefits form (DE 2501F) completed and signed by the care recipient’s physician/practitioner.
❑ You may request for the care recipient’s City of Hope physician or care practitioner to complete Part D by submitting in-person to your health care team.

Please allow up to 10 business days for the request to be processed by City of Hope. The physician/practitioner may submit the certification using SDI Online, or they can complete and sign the paper form.

It is your responsibility to have the physician/practitioner complete and sign the form and submit it to the EDD within 41 days from the date your family leave begins or you may lose benefits.

STEP 3: Mail the completed Claim for Paid Family Leave Benefits Form (DE 2501F).
To submit the claim, mail the completed paper claim form to the EDD in the
pre-addressed envelope to:

State of California
Employment Development Department
P.O. Box 989315
West Sacramento, CA 95798-9315

IMPORTANT – Be reminded:
❑ Make sure to put a stamp on the envelope.
❑ Mail your claim no earlier than the first day your family leave begins, but no later than 41 days after your family leave begins or you may lose benefits.
❑ A properly completed application will include:
❍ Part A — Claimant’s Statement of the Claim for Paid Family Leave Benefits form (DE 2501F)
❍ Part C — Statement of Care Recipient of the form
❍ Part D — Physician/Practitioner’s Certification of the form
❍ Care Recipient’s Authorization for Disclosure of Personal Health

Resources
SDI Online Claimant Tutorial
edd.ca.gov/Disability/pdf/sdi-online-tutorial-claimant.pdf

Frequently Asked Questions
— edd.ca.gov/FAQ_-_Benefit_Programs_Online.htm

Benefit Programs Online Overview and Registration (YouTube)
youtu.be/OUsh6ZwLd0k

Form DE 2501F
forms.edd.ca.gov/forms

EMPLOYMENT DEVELOPMENT DEPARTMENT (EDD) WALK-IN LOCATIONS:

If you have problems completing your disability or paid family leave application online or on paper, you may want to call or visit the EDD walk-in offices listed below.


LA Works One-Stop Career Center
5200 Irwindale Ave.
Irwindale, CA 91706
Monday, Thursday and Friday — 8 a.m. to 5 p.m.
Tuesday and Wednesday — 8 a.m. to 7 p.m.
First and third Saturday — 9 a.m. to noon
(626) 960-3964

Inglewood South Bay One-Stop Business
and Career Center
110 South La Brea Ave., 5th Floor
Inglewood, CA 90301
Monday to Thursday — 8 a.m. to 6 p.m.
Friday — 8 a.m. to 5 p.m. (Closed alternate Fridays)
(310) 680-3700

Hub Cities One-Stop Career Center
2677 Zoe Ave., 1st Floor
Huntington Park, CA 90255
Monday to Friday — 8:30 a.m. to 5 p.m.
(323) 586-4700

Verdugo Jobs Center
1255 South Central Ave.
Glendale, CA 91204
Monday to Friday — 8:30 a.m. to 5 p.m.
(818) 409-0476

LA South | Compton Workforce Service Office
2909 East Pacific Commerce Drive
Compton, CA 90221
Monday to Friday — 7 a.m. to 6 p.m.
(310) 223-2901

Cerritos Career Center
10900 E 183rd St., Suite 350
Cerritos, CA 90703
Monday to Friday — 8 a.m. to 5 p.m.
(562) 402-9336

Chino Hills
15315 Fairfield Ranch Road, Suite 100
Chino Hills, CA 91709
Monday to Friday — 8 a.m. to 5 p.m.
(800) 480-3287

Long Beach
4300 Long Beach Blvd., Suite 600
Long Beach, CA 90807-2011
Monday to Friday — 8 a.m. to 5 p.m.
(800) 480-3287

Los Angeles
888 South Figueroa St., Suite 200
Los Angeles, CA 90017-5449
Monday to Friday — 8 a.m. to 5 p.m.
(800) 480-3287

San Bernardino
371 West 3rd St.
San Bernardino, CA 92401
Monday to Friday — 8 a.m. to 5 p.m.
(800) 480-3287

Santa Ana 2 MacArthur Place, Suite 400
Santa Ana, CA 92707
Monday to Friday — 8 a.m. to 5 p.m.
(800) 480-3287

Van Nuys
15400 Sherman Way, Room 500
Van Nuys, CA 91406
Monday to Friday — 8 a.m. to 5 p.m.
(800) 480-3287