How to complete DE 2501 Part B (California SDI)
DE 2501 is California's application for State Disability Insurance benefits. Part B is the physician or practitioner's certificate. This guide walks through Part B in the form's order, and explains how EDD takes your answers.
- Form
- California SDI: answers for Part B of the DE 2501 (Physician/Practitioner's Certificate)
- Issued by
- California Employment Development Department
- Revision
- Questions B4 to B32 of DE 2501 Rev. 82 (10-24)
- Checked against the source
- November 5, 2026
What it is and when it is used
A California worker who cannot do their regular or customary work because of a disability applies to the Employment Development Department (EDD) for State Disability Insurance. EDD needs both parts: Part A from the claimant and Part B from their licensed health professional.
You can certify Part B in SDI Online or on Part B of the paper application. If you use paper, EDD asks that it be submitted with Part A.
The PDF of DE 2501 on the EDD website is marked as a sample, for reference only.
Who completes which part
| Part | Completed by | What it covers |
|---|---|---|
| Part A | Claimant (the patient) | Personal details, work history and the claim itself, signed by the claimant. |
| Part B | Physician or practitioner | The certificate: your license details, the patient's disability dates, diagnosis, findings and treatment, and your certification under penalty of perjury. |
The provider's part, section by section
Questions B1 to B3 identify the claim. The clinical certificate runs from B4 to B32, then B33 is your signed certification.
B4 to B11: patient and practitioner
B4 and B5 are the patient's date of birth and name. B6 to B11 are yours: license number, the state or country that issued it, license type, specialty, your name as shown on the license, and your address (with a facility address if you work at a county hospital or government facility).
B12 to B14: care and disability dates
B12 is the period the patient has been under your care for this problem, whether you are still treating them, and how often you see them.
B13 asks whether the patient has been unable to do their regular or customary work at any time during your care, and the date the disability began. It also asks whether an accident or trauma caused it, and when.
B14 is the date you released, or expect to release, the patient to their regular or customary work. The form says answers like "unknown" or "indefinite" are not accepted. If the disability is permanent and you never expect to release them, check that box instead.
B15 to B18: pregnancy
B15 is the estimated delivery date or the date the pregnancy ended, and the type of delivery. B17 asks, when you do not expect to release the patient before delivery, how many days of disability you expect after a vaginal and after a cesarean delivery. B18 is any complication of an abnormal pregnancy or delivery that causes disability.
B19 to B22: diagnosis and findings
B19 is the ICD diagnosis code for the condition that keeps the patient from their regular or customary work, primary first, then any secondary codes. The form marks it required.
B20 is the diagnosis, also required. If no diagnosis has been made, give a detailed statement of the symptoms. B21 is your findings: the nature, severity and extent of the condition, and any other disabling conditions. B22 is the treatment or medication you have given.
B23 to B28: hospital, other providers, procedures
B23 is any hospital stay, with admission and discharge dates. B24 is for a patient who has died. B26 asks whether another practitioner or facility saw the patient first for this disability, and the date of first treatment. B27 is the date and type of the latest or planned surgery or procedure, and whether the patient could not work before it. B28 is the ICD procedure codes and CPT codes, without modifiers.
B29 to B32: work cause and other questions
B29 asks whether the patient's regular or customary work caused or aggravated the condition. B30 and B31 cover a referral to an alcoholic recovery home or drug-free residential facility. B32 asks whether disclosing the information on the form would be medically or psychologically detrimental to the patient.
B33: your certification
You certify under penalty of perjury that the patient cannot do their regular or customary work because of the listed condition, that you examined or treated them, and that you are authorized to certify under the California Unemployment Insurance Code. On paper, the form asks for your original signature and says a rubber stamp is not accepted.
Deadlines the form states
- The form tells the claimant to submit the application within 49 days of the date the disability began, to avoid losing benefits.
Where it goes
Enter your answers in SDI Online, or write them on Part B of the EDD-issued paper application, which is submitted with Part A.
Official source
Questions B4 to B32 of DE 2501 Rev. 82 (10-24). Checked against the issuer's copy on November 5, 2026. This guide paraphrases the form's own instructions; the form and California Employment Development Department are the authority.
How Scribeable fills it
Scribeable writes an answer sheet for questions B4 to B32, in the form's order, from your visit note. It is not an EDD form and is not submitted to EDD.
It writes an answer only when the note states it. Anything the note does not say stays blank for you. The Social Security number lines and B32, which is your own judgment, are always left for you.
Each answer shows the sentence in the note it came from, so you can check it.
You review the sheet, then copy the answers into SDI Online or onto the EDD-issued paper form, and certify and sign there.
Other forms
- FMLA, employee (WH-380-E)U.S. Department of Labor, Wage and Hour Division
- FMLA, family member (WH-380-F)U.S. Department of Labor, Wage and Hour Division
- NY disability benefits (DB-450)New York State Workers' Compensation Board
- NY workers' comp narrative (CMS-1500 template)New York State Workers' Compensation Board
- CA workers' comp progress report (PR-2)California Division of Workers' Compensation
- FL disabled parking permit (HSMV 83039)Florida Department of Highway Safety and Motor Vehicles
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