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Get Authorization To Release A Medical Certificate

To all family members claiming Employment Insurance (EI) Compassionate Care Benefits, as well as to ESDC. Signature Date (dd-mm-yyyy) Section 2- PATIENT REPRESENTATIVE To be completed by patient's legally authorized or appointed representative if, due to illness, Section 1 is not signed by patient. Patient's Representative (Print Name) Relationship to Patient in Kinship or Law Telephone Number with Area Code I am legally appointed or authorized to consent to the disclosure of this patient'.

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