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SC Ins5257

This document is an authorization form for patients to release their medical information for Employment Insurance compassionate care and family caregiver benefits. Patients or their legal representatives must complete and sign the form to allow medical professionals to share necessary information with Employment and Social Development Canada. The form also includes a privacy notice regarding the handling of personal information provided.

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Redae Berihu
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398 views1 page

SC Ins5257

This document is an authorization form for patients to release their medical information for Employment Insurance compassionate care and family caregiver benefits. Patients or their legal representatives must complete and sign the form to allow medical professionals to share necessary information with Employment and Social Development Canada. The form also includes a privacy notice regarding the handling of personal information provided.

Uploaded by

Redae Berihu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Service PROTECTED WHEN COMPLETED - B

Canada

Authorization to Release Medical Information for


Employment Insurance Compassionate Care and Family Caregiver Benefits
Medical information about a patient can’t be released without the patient’s consent.

To authorize a medical doctor or nurse practitioner to release medical information, the patient must complete and sign this form. If the patient is below the age of
consent in the jurisdiction where this form is completed or is unable to authorize the release of medical information because of a physical or mental condition, the
patient’s legal representative can complete and sign this form.

This form must be presented to the medical doctor or nurse practitioner who will complete and sign the medical certificate required to receive Employment
Insurance (EI) compassionate care or family caregiver benefits.

The individual requesting EI compassionate care or family caregiver benefits must submit this form at the same time as the medical certificate. If the
patient or legal representative does not consent to the release of the required medical information, we will be unable to process the application for EI
compassionate care or family caregiver benefits.

Patient information
Last name Given name(s) Date of birth (YYYY-MM-DD)

Home address
Apartment number Street number and name City or town

Province, territory or state Postal or ZIP code Country

Patient's signature
I authorize my doctor or nurse practitioner to release my medical information included on the medical certificate to Employment and Social Development Canada
(ESDC) and to the family member(s) who are claiming EI compassionate care or family caregiver benefits.

Patient's signature Date (YYYY-MM-DD)

Or
Signature of patient's representative
I am legally authorized to consent to release this patient’s medical information.

I authorize the patient’s doctor or nurse practitioner to release the patient’s medical information included on the medical certificate to ESDC and to the family
member(s) who are claiming EI compassionate care or family caregiver benefits.

Representative's signature Date (YYYY-MM-DD)

Name of representative (please print) Relationship to patient Telephone number (999) 999-9999

Privacy Notice Statement

The personal information provided on this form:


• is collected under the authority of the Employment Insurance Act and the Department of Employment and Social Development Act to determine the eligibility of
one or multiple claimants for EI compassionate care or family caregiver benefits;
• will be managed and administered in accordance with the Department of Employment and Social Development Act, the Privacy Act and other applicable laws;
• may be shared by ESDC with federal departments and agencies involved in the administration of benefits and services, or with federal and provincial
departments for the administration and enforcement of the legislation for which they are responsible;
• may be used or disclosed for policy analysis, research or evaluation purposes. These uses or disclosures will not result in any decision that directly affects the
claimant or any other individual whose information is included on this form;
• is described in the Personal Information Bank: Employment Insurance Claim Files (PIB) (ESDC PPU 151).
Individuals have the right to the protection of, access to and correction of their personal information. Instructions for obtaining the personal information provided
on this form are outlined in the government online publication Info Source available at www.canada.ca/infosource-ESDC. Info Source can also be accessed at
any Service Canada Centre. Individuals who are not satisfied with ESDC’s response to their privacy concerns can contact the
Office of the Privacy Commissioner of Canada at www.priv.gc.ca/en/report-a-concern.

SC INS5257 (2025-01-001) E Page 1 of 1

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