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Claim for Disability Insurance (DI) Benefits - Claimant's Statement (DE 2501) Form Receipt Number:

R100000125034752

Section 1 - Personal Information Social Security Number: EDD Customer Account Number:

XXX-XX-6726 4567905835

Legal Name: California Driver License or ID Number: Date of Birth: Gender:

Joselyn perla B8551978 01-30-1979 Female

Preferred Language:

English

Mailing Address:

107 Chadwick Ave Linwood, PA 19061-4310 United States

Residence Address:

16026 Liggett St North Hills, CA 91343-3049 United States

Home Phone Number: Cell Phone Number:

717-745-7112

Section 2 - Other Names and Social Security Numbers Used Please enter any other names or other Social Security Numbers under which you have worked. If you have never worked under another name or Social Security Number please leave this section blank. Name: Name: Social Security Number: Social Security Number: Section 3 - Employment Information Are you self employed? Are you a State Government employee? If “Yes,” indicate bargaining unit number:

No No

At any time during your disability, were you in the custody of law enforcement authorities because you were convicted of violating law or ordinance? Before your disability began, what was the last day you worked? When did your disability begin?

No

09-08-2021 09-09-2021

Date you want your DI claim to begin if different than the date your disability began: Since your disability began, have you worked or are you No working any full or partial days? Have you recovered? No If ”Yes,” enter date: Have you returned to work? If ”Yes,” enter date: DE 2501

No 1 of 7

What is your regular or customary occupation? Why did you stop working? How would you describe or classify your job?

Has or will your employer continue to pay you during your disability leave? If “Yes,” indicate type(s) of pay: Other type of pay:

Operation manager Illness, Injury or Pregnancy Walking/standing most of the time; occasionally lift, carry, push, pull or otherwise move objects that weigh up to 20 lbs. No

May we disclose benefit payment information to your employer Yes (s)? Do you have more than 2 employers? No Have you filed or do you intend to file for Workers’ No Compensation benefits? Was this disability caused by your job? No Are you a resident of an alcohol recovery home or a drug-free No facility? Section 4 - List of Employers Your Last or Current Employer Address Employer(s) livemoore forb

Employer Phone Number

16026 Liggett St North Hills, CA 91343-3049 United States

Section 5 - Alcohol Recovery or Drug-Free Facility Information Name of Facility: Address: Phone Number: Section 6 - Workers' Compensation Information Workers’ Compensation Claim Number: Workers’ Compensation Appeals Board/ADJ Case Number: Date(s) of injury shown on your Workers’ Compensation Claim: Employer's name shown on your Workers' Compensation Claim: Employer’s Phone Number: Section 7 - Workers' Compensation Insurance Company Workers’ Compensation Insurance Company Name: Workers’ Compensation Insurance Company Address: Workers’ Compensation Insurance Company Phone Number: Adjuster’s Name: Adjuster’s Phone Number:

DE 2501

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Last Day Worked 09-08-2021

Section 8 - Your Workers' Compensation Case Attorney Information Attorney’s Name: Attorney’s Address: Attorney’s Phone Number: Section 9 - Payment Choice EDD Debit Card Preferred Payment Method:

I acknowledge that I Yes have reviewed the EDD Debit Card Fee Disclosures.

Section 10 - 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 such violation is punishable by imprisonment or fine or both. I declare under penalty of perjury that the foregoing statement, including any accompanying statements, is to the best of my knowledge and belief true, correct, and complete. By my signature on this claim statement, I authorize the California Department of Industrial Relations and my employer to furnish and disclose to State Disability Insurance all facts concerning my disability, wages or earnings, and benefits payments that are within their knowledge. By my signature on this claim statement, I authorize release and use of information as stated in the “Information Collection and Access” section of the Important Disability Insurance Program Information page. I agree that photocopies o this authorization shall be as valid as the original, and I understand that authorizations contained in this claim statement are granted for a period of fifteen years from the date of my signature or the effective date of the claim, whichever is later. Health Insurance Portability and Accountability Act (HIPAA) Authorization I authorize Physician/Practitioner/Organization:

Dr.Kathleen savage

to furnish and disclose all my health information and to allow inspection of and provide copies of any medical, vocational rehabilitation, and billing records concerning my disability for which this claim is filed that are within their knowledge to the following employees of the California Employment Development Department (EDD): Disability Insurance Branch examiners, their direct supervisors/managers and any othe EDD employee who may have a need to access this information in order to process my claim and/or determine eligibility for State Disability Insurance benefits. I understand that EDD is not a health plan or health care provider, so the information released to EDD may no longer be protected by federal privacy regulations. (45 CFR Section 164.508(c)(2)(iii)). EDD may disclose information as authorized by the California Unemployment Insurance Code. I agree that photocopies of this authorization shall be as valid as the original. I understand I have the right to revoke this authorization by sending written notification stopping this authorization to the EDD, DI Branch MIC 29, PO Box 826880, Sacramento, CA 94280. The authorization will stop on the date my request is received. I understand that the consequences for my revoking this authorization may result in denial of further State Disability Insurance benefits. I understand that, unless revoked by me in writing, this authorization is valid for fifteen years form 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 to prevent EDD’s recovery of monies to which it is legally entitled. I understand that I am signing this authorization voluntarily and that payment or eligibility for my benefits will be affected if I do not sign this authorization. The consequences for my refusal to sign this authorization may result in an incomplete claim form that cannot be processes for payment of State Disability Insurance benefits. I understand I have the right to receive a copy of this authorization. Claimant Signed:

Yes

Signed by Mark (X)? DE 2501

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Date Signed:

11-14-2021

HIPAA Signed?

Yes

Witness Information Witness 1 Name:

Date Signed:

Address: Witness 2 Name:

Date Signed:

Address: Personal Representative Information Personal Representative signing on behalf of claimant?

Represents the claimant in this matter as authorized by:

Personal Representative Name:

Date Signed:

Confirmation You are responsible for providing your claim receipt number to your physician/practitioner so they may complete and submit a medical certification for your claim. Your claim form is not complete without the Physician/Practitioner's Certificate. For faster processing, your physician/practitioner may complete and submit this form online at www.edd.ca.gov. Alternatively, your physician/practitioner may submit the Physician/Practitioner's Certificate using the pape “Claim for Disability Insurance (DI) Benefits”, DE 2501 form and mailing it to the EDD. Have your physician/practitioner complete and sign “Part B – PHYSICIAN/PRACTITIONER’S CERTIFICATE.” Certification may be made by a licensed physician or practitioner authorized to certify to a patient’s disability or serious health condition pursuant to California Unemployment Insurance Code, Section 2708. I you are under the care of an accredited religious practitioner, obtain a “Claim for Disability Insurance Benefits - Religious Practitioner’s Certificate,” DE 2502, by calling 1-800-480-3287 and ask your religious practitioner to complete and sign it. Rubber stamp signatures are not accepted. Your completed claim form must be received no earlier than 9 days, but no later than 49 days, after the firs day you became disabled. If your completed claim form is late, you may lose benefits. Most claims are processed within 14 days of receipt of a properly completed claim form, which includes your portion of the DE 2501 and the Physician/Practitioner’s Certificate. If you are receiving temporary workers’ compensation benefits and are filing for reduced Disability Insurance benefits for the same days, “PART B – PHYSICIAN/PRACTITIONER’S CERTIFICATE” of this form is not required, however after filing, contact SDI by calling 1-800-480-3287. Submitted By:

Joselyn perla

Submitted On:

11-14-2021 04:26 PM

Entered By:

Joselyn perla

Entered Date:

11-14-2021 04:26 PM

Claim for Disability Insurance (DI) Benefits - Physician/Practitioner's Certificate (DE 2501) Form Receipt Number:

R100000129427843

Section 1 - Patient Information Patient’s Name: DE 2501

Joselyn perla 4 of 7

Receipt Number:

R100000125034752

Social Security Number:

XXX-XX-6726

Date of Birth:

01-30-1979

File Number: Section 2 - Physician/Practitioner Information Name:

TERRE LEGREID OSTERKAMP

License Number:

G40344

State of Licensure:

CA

Treatment Address:

1809 Verdugo Blvd Ste 350 Glendale, CA 91208-1476 United States

Phone Number:

818-790-8121

License Type:

Physician or Surgeon (MD)

Specialty (if any): Section 3 - Treatment Information This patient has been under my care and treatment for this medical problem: From:

08-12-2021

To:

01-17-2022

Are you presently treating the patient for this medical condition?

Yes

Treatment Intervals:

Bi-Weekly

Was the patient seen previously by another physician/practitioner or medical facility for the current disability/illness/injury?

No

If "Yes," enter the date of first treatment? At any time during your attendance for this medical problem, No has the patient been incapable of performing his/her regular or customary work? Section 4 - Claim Information Date Disability Began: Was the disability caused by an accident or trauma? If "Yes," indicate the date the accident or trauma occurred Date you released or anticipate releasing patient to return to his/her regular or customary work: Patient’s disability is permanent and you never anticipate releasing patient to return to his/her regular or customary work: Enter the ICD Diagnosis Code and version for the primary disabling condition that prevents the patient from performing his/her regular or customary work below: ICD Diagnosis Code: DE 2501

Diagnosis Code Version: 5 of 7

ICD Diagnosis Code(s) for Secondary Disabling Condition(s): ICD Diagnosis Code:

Diagnosis Code Version:

ICD Diagnosis Code:

Diagnosis Code Version:

ICD Diagnosis Code:

Diagnosis Code Version:

Diagnosis - If no diagnosis has been determined, enter a detailed statement of symptoms: Findings - State nature, severity, and extent of the incapacitating disease or injury, including any other disabling conditions: Type of treatment/medication rendered to patient: If patient was hospitalized, date of entry: Date of discharge: Patient is still hospitalized? Is the patient deceased? Date of death: City: County: State: Type of surgery/procedure: Date of surgery/procedure: Enter the ICD Procedure Code and version for surgery/procedure(s) planned or performed below: ICD Procedure Code:

Procedure Code Version:

ICD Procedure Code:

Procedure Code Version:

ICD Procedure Code:

Procedure Code Version:

ICD Procedure Code:

Procedure Code Version:

Enter the CPT code for surgery/procedure(s) planned or performed below: CPT Code: CPT Code: CPT Code: CPT Code: Was the patient unable to work immediately prior to the surgery or procedure? If “Yes,” please provide the first date the patient was unable to work prior to the surgery or procedure? Was this disabling condition caused and/or aggravated by the patient’s regular or customary work? Are you completing this form for the sole purpose of referral/recommendation to an alcoholic recovery home or drug-free residential facility (as indicated by the patient on the DE 2501 Claim for Disability Insurance (DI) Benefits Claimant’s Statement)? Date your patient became a resident of a drug or alcohol facility (if known): DE 2501

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Would disclosure of the information on this form be medically or psychologically detrimental to your patient? Is this a pregnancy related claim? Section 5 - Pregnancy Information Estimated Delivery Date: Pregnancy End Date (if applicable): If this patient has not delivered and you do not anticipate releasing the patient to return to regular and customary work prior to the estimated delivery date, provide estimates for the number of days you anticipate the patient will be disabled after delivery for the both of the following delivery types: Vaginal delivery: Cesarean delivery: If this patient has delivered, indicate type of delivery and any complications as applicable. Type of Delivery: If pregnancy is/was abnormal, state the complication(s) causing maternal disability: Section 6 - Prognosis Information What complications make your patient disabled longer than normally expected? Section 7 - Physician/Practitioner’s Certification Title of Person:

An authorized physician or practitioner pursuant to California Unemployment Insurance Code Section 2708. I certify under penalty of perjury that the patient is unable to perform his/her regular or customary work because of the listed disabling condition(s). I have performed a physical examination and/or treated the patient within my scope of practice as an authorized physician or practitioner pursuant to California Unemployment Insurance Code Section 2708. Physician/Practitioner Signed:

Yes

Date Signed: If government facility, provide facility name: If government facility, provide facility address:

01-17-2022

Under Section 2116 and 2122 of the California Unemployment Insurance Code, it is a violation for any individual who, with the intent to defraud, falsely certifies the medical condition 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 fine not exceeding twenty thousand dollars. Section 1143 requires additional administrative penalties. Submitted By: Entered By:

DE 2501

TERRE LEGREID OSTERKAMP TERRE L OSTERKAMP

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Submitted On: Entered Date:

01-17-2022 12:48 AM 01-17-2022 12:48 AM...