Medical Ei Form PDF Details

The Medical Certificate for Employment Insurance Compassionate Care Benefits serves a crucial role in ensuring eligible workers can provide care or support to a family member who is gravely ill, with a significant risk of death within the next 26 weeks. It embodies a compassionate approach towards employees needing to take time off to tend to seriously ill loved ones, highlighting the importance of emotional and psychological support alongside direct care. The form requires completion by a medical practitioner, under specific conditions, to certify the patient’s serious health condition and the necessity for family member(s) support within this critical period. Additionally, it acknowledges that in certain circumstances, benefits might be requested for a period prior to the date of certification, provided the medical professional confirms the patient's eligibility based on their condition during the said timeframe. Integration with an authorization form for releasing medical information underscores the procedural and confidential nature of applying for these benefits. Furthermore, it inclusively addresses situations where a medical doctor’s direct intervention is impractical, allowing designated health practitioners to fulfill this role, ensuring that geographical constraints do not hinder access to compassionate care benefits. Thus, the documentation process, detailed on the Service Canada website, is designed to facilitate a smoother application for support during challenging times. Through this compassionate care initiative, the government acknowledges the critical role of family in healthcare and the need for policies that support work-life balance during terminal illnesses.

QuestionAnswer
Form NameMedical Ei Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmedical certificate ei pdf, ontario medical ei form, medical ei form pdf, service canada medical certificate form

Form Preview Example

Service

PROTECTED WHEN COMPLETED - B

Canada

 

Medical Certificate for Employment Insurance Compassionate Care Benefits

The Authorization to Release this medical information is a separate form and will be provided by the individual requesting that you complete this Medical Certificate for Employment Insurance Compassionate Care Benefits. This certificate and the Authorization form must be submitted together when a claim for compassionate care benefits is made.

Employment Insurance Compassionate Care benefits are available to eligible workers to provide care or support to a family member who is gravely ill with a significant risk of death within 26 weeks (patient).

For more information about the Compassionate Care Benefit, go to: servicecanada.gc.ca/eng/ei/types/compassionate_care.shtml

Note: For Employment Insurance benefit purposes, care or support is defined as:

-directly providing or participating in the care of the patient, or

-providing psychological or emotional support for the patient, or

-arranging for the care of the patient by a third party care provider.

Important: A Medical Practitioner (Health Practitioner other than a Medical Doctor) may complete this form when:

-the patient is in a geographical location where treatment by a Medical Doctor is not readily available AND

-the Medical Practitioner is designated by a Medical Doctor to provide treatment to the patient.

A. Patient's Name

 

 

Date of Birth (d-m-y)

 

 

 

 

 

B. I last examined the patient on

 

and certify that the following conditions exist:

 

 

 

 

 

 

(d-m-y)

1. The patient has a serious medical condition and a significant risk of death within the next 26 weeks (6 months).

2. The patient requires the care or support of one or more family members within this 6 months.

Yes

No

Yes

No

C. Compassionate care benefits are payable to eligible family members from the date in B above or the week this medical is signed. In some situations, these benefits are being requested for an earlier period of time and may be payable for this period if you certify that the 2 conditions in B above applied to your patient for an earlier period of time.

3. Did the two conditions in B above apply to your patient for an earlier period within the past 6 months?

Yes

D.(If applicable)

No

If yes, please provide the earlier date (d-m-y)

In my professional opinion and to the best of my knowledge, the patient identified above is unable to give consent to the release of medical information because

of his age, a physical or mental condition.

Yes

Signature (Medical Doctor or

Date (d - m - y)

Practitioner designated by the Doctor)

Contact Information

Medical Doctor, or Medical Practitioner (Health Practitioner), designated by the Doctor (identified above)

Name

Specialty

License Number

Apt no or suite no

Number and Street, Concession, Other

City or Town

Province/Territory

Country

Telephone Number with Area Code

Postal Code (if in Canada)

Non-Canadian Doctors or Non-Canadian Medical Practitioners

Please provide the following information:

-the name of the university - the country and the year you obtained your certification

-your hospital or clinic affiliation and your license number

University

Country

Year (d - m - y)

Hospital/Clinic Affiliation

License Number

Service Canada delivers Human Resources and Skills Development Canada programs and services for the Government of Canada

SC INS5216B (2012-01-006) E

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Stage number 1 for submitting ontario medical ei form

2. Now that this segment is done, you should put in the essential specifics in The patient has a serious medical, The patient requires the care or, Yes, Yes, C Compassionate care benefits are, Did the two conditions in B above, Yes, If yes please provide the earlier, D If applicable, In my professional opinion and to, of his age a physical or mental, Yes, Signature Medical Doctor or, Contact Information, and Date d m y so you're able to proceed to the next part.

The right way to fill in ontario medical ei form portion 2

Be really attentive while filling out Yes and If yes please provide the earlier, since this is where most users make a few mistakes.

3. In this specific step, review University, Country, Year d m y, HospitalClinic Affiliation, License Number, Service Canada delivers Human, SC INSB E, and Page of. Each one of these should be filled in with greatest awareness of detail.

Guidelines on how to fill out ontario medical ei form stage 3

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