|Title||INS5216A: Authorization to Release a Medical Certificate, INS5216B: Medical Certificate for Employment Insurance Compassionate Care Benefits|
INS5216A: Have this form completed by the patient or their legal representative authorizing the medical doctor to complete the medical certificate for compassionate care benefits.
INS5216B: Have this form completed by a medical doctor if you are asking for compassionate care benefits. You must return these 2 forms together by mail or deliver them to your local Service Canada Centre. Please note that the fees requested by your doctor to complete these forms are entirely at your own expense.
Returning the Form
This site uses PDF form technology. To print these high-quality PDF forms, you must have a PDF reader installed. If you do not already have such a reader, there are several available on the Internet: Adobe Reader and Foxit Reader are popular examples.
The form(s) are available in the following formats: PDF.
To access the Portable Document Format (PDF) version you must have a PDF reader installed. If you do not already have such a reader, there are several PDF readers available on the Internet.
Authorization to Release a Medical Certificate
PDF, sc-ins5216a(2012-01-006)e.pdf, 500 KB, printed on 1 page
Medical Certificate for Employment Insurance Compassionate Care Benefits
PDF, sc-ins5216b(2012-01-006)e.pdf, 626 KB, printed on 1 page
For more information, please consult the Forms Help page.
- Date modified: