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Get Canada SC INS5216A 2017-2024

Service Canada delivers Employment and Social Development Canada programs and services for the Government of Canada SC INS5216A 2012-01-007 E Page 1 of 1. Service Canada PROTECTED WHEN COMPLETED - B Authorization to Release a Medical Certificate This form is an Authorization for the release of medical information and must be completed and shown to the Medical Doctor or other Medical Practitioner Health Practitioner who will complete the Medical Certificate for Employment Insurance Compassionate Care Benefits. This form and the Medical Certificate for Employment Insurance Compassionate Care Benefits must be submitted together when making a claim for Compassionate Care benefits. The information provided on this form and the Medical Certificate for Employment Insurance Compassionate Care Benefits is collected by Employment and Social Development Canada ESDC under the authority of the Employment Insurance Act EI to determine the eligibility for compassionate care benefits of one or more family members of a seriously ill individual* Failure to complete this form and the Medical Certificate for Employment Insurance Compassionate Care Benefits may result in family members not being entitled to receive compassionate care benefits. and control of ESDC may be linked* In some instances information may be disclosed without consent according to the EI Act. The personal information collected herein is administered in accordance with the EI Act and Privacy Act which states that individuals have the right to the protection of and access to their personal information and have the right to request changes to incorrect information* It will be retained for six years after the last administrative action as described in Personal Information Bank Insurance Claim File - Local Office ESDC PPU 150. Instructions for obtaining this information are outlined in the government publication entitled Info Source a copy of which is located at all Service Canada Centres. Info Source is also located at the following web site address infosource. gc*ca Note - A Medical Doctor or other Medical Practitioner Health Practitioner may request a fee to fill out the Medical Certificate for Employment Insurance - A claimant may avoid unnecessary costs by not submitting the Medical Certificate for Employment Insurance Compassionate Care Benefits if one has already been submitted by any family member for the same patient in the last 26 weeks 6 months. Section 1- PATIENT INFORMATION If the ill person patient is incapable of consenting to the release of medical information Sections 1 and 2 must be completed by the patient s Legally Authorized or Appointed Representative and the Medical Doctor or Practitioner must complete Section D of the Medical Certificate for Employment Insurance Compassionate Care Benefits. Patient s Family name All given names Date of birth dd-mm-yyyy Residential address Apartment no. Number and Street Concession Other City or Town Province/Territory/State/Region/County Country Postal Code if in Canada I hereby authorize the release of the information provided in the Medical Certificate for Employment Insurance Compassionate Care Benefits to all family members claiming Employment Insurance EI Compassionate Care Benefits as well as to ESDC.

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