hector regalado
Pico Rivera,CA
Overview
2
2
Languages
Accomplishments
- Of 4DE 2501
- What is your regular or customary occupation
- Licensed Vocational Nurse
- Why did you stop working
- Illness, Injury or Pregnancy
- How would you describe or classify your job
- Walking/standing most of the time; occasionally lift, carry, push, pull or otherwise move objects that weigh up to 20 lbs
- Has or will your employer continue to pay you during your disability leave?
- No
- If “Yes,” indicate type(s) of pay:
- Other type of pay:
- May we disclose benefit payment information to your employer (s)?
- Yes
- Do you have more than 2 employers
- No
- Have you filed or do you intend to file for Workers’
- Compensation benefits?
- No
- Was this disability caused by your job
- No
- Are you a resident of an alcohol recovery home or a drug-free facility?
- No
- Section 4 - List of Employers
- 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:
- Your Last or Current
- Employer(s)
- Employer Address Employer Phone
- Number
- Last Day Worked
- AltaMed 5425 Pomona Blvd
- Los Angeles, CA 90022-1716
- United States728-0411 10-13-2023of 4DE 2501
- Section 8 - Your Workers' Compensation Case Attorney Information
- Attorney’s Name:
- Attorney’s Address:
- Attorney’s Phone Number:
- Section 9 - Payment Choice
- Preferred Payment
- Method:
- EDD Debit Card I acknowledge that I have reviewed the
- EDD Debit Card Fee
- Disclosures
- Yes
- 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 of 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: George Mutafyan
- MD 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 other
- 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 Date Signed: 10-20-2023of 4DE 2501
- Signed by Mark (X)
- HIPAA Signed
- Yes
- Witness Information
- 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 paper “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
- If 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 first 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: Erica Regalado Submitted On: 10-20-202305 AM
- Entered By: Erica Regalado Entered Date: 10-20-202305 AM
- Witness 1 Name: Date Signed:
- Address:of 4DE 2501