Ins5216a 2025

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The document is an Authorization to Release a Medical Certificate for Employment Insurance Compassionate Care Benefits, which must be completed and submitted alongside the Medical Certificate when claiming benefits for family members of a seriously ill individual. It outlines the collection and use of personal information by Employment and Social Development Canada (ESDC) under the Employment Insurance Act, emphasizing the importance of completing both forms to ensure eligibility for benefits. It also includes sections for patient information and authorization by a legally appointed representative if the patient cannot consent.

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Click ‘Get Form’ to open the ins5216a in the editor.
Begin with Section 1, 'PATIENT INFORMATION'. Fill in the patient's family name, all given names, and date of birth. Ensure that the residential address is complete, including apartment number, street, city, province/territory/state, country, and postal code if applicable.
In Section 1, authorize the release of medical information by signing and dating the form. This step is crucial for allowing family members to claim Employment Insurance Compassionate Care Benefits.
If the patient cannot consent due to illness, proceed to Section 2. Here, the legally authorized representative must print their name, state their relationship to the patient, and provide a contact telephone number.
The representative must sign and date this section as well, confirming their authority to disclose medical information for completing the Medical Certificate.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (40 Votes)
2012	4 Satisfied (23 Votes)

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