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 fa....
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How to fill out the Canada SC INS5216A online
The Canada SC INS5216A form is essential for authorizing a medical professional to release information needed for Employment Insurance Compassionate Care Benefits. This guide provides a clear and supportive approach to help you navigate the online filling process.
Follow the steps to successfully complete the form.
- Click the ‘Get Form’ button to access the Canada SC INS5216A and open it for completion.
- Enter the patient’s information: Fill in the last name, given name(s), and date of birth in the specified format (yyyy-mm-dd). Provide the home address, including apartment number, street number and name, province or territory, city or town, postal or ZIP code, and country.
- Signature Section: The form requires the patient's signature authorizing the doctor or nurse practitioner to release medical information to Employment and Social Development Canada (ESDC). The patient must sign and date the form.
- If the patient is unable to sign, the legally authorized representative should complete the signature section, indicating their relationship to the patient and providing their own signature, name, and phone number.
- Review all the filled fields for accuracy. Ensure that all required information is completed correctly before submitting.
- Save changes, download, print, or share the completed form as required, ensuring that you retain a copy for your records.
Complete the Canada SC INS5216A online today to ensure your application for Compassionate Care Benefits is processed smoothly.
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