Form SC INS5216B at a glance
What it is: Medical Certificate for Employment Insurance Compassionate Care Benefits.
Who signs: Sign on the Signature (Medical doctor or nurse practitioner) line and enter the Date (YYYY-MM-DD).
The individual requesting that you complete this form must present to you the Authorization to Release Medical Information for Employment Insurance Compassionate Care and Family Caregiver Benefits form.
A medical doctor or nurse practitioner must complete and sign a medical certificate attesting that the patient has a serious medical condition with a significant risk of death in the next 26 weeks and requires the care or support of one or more family members. Only one medical certificate needs to be completed, even if 2 or more caregivers intend to claim benefits.
A filled-in Form SC INS5216B example: a doctor completes the certificate
How to fill out Form SC INS5216B, box by box
A. Patient
In A, enter the Patient last name, Patient given name(s) and Date of birth (YYYY-MM-DD).
B. The date you last examined the patient and the 2 conditions
In B, enter the date you last examined the patient as Date (YYYY-MM-DD) after "I last examined the patient on".
Yes or No: The patient has a serious medical condition with a significant risk of death within the next 26 weeks.
Yes or No: The patient requires the care or support of one or more family members over the next 26 weeks.
C. An earlier period
Compassionate care benefits are payable to eligible individuals from the date indicated in B or the week this medical certificate is signed.
In some situations, these benefits may be requested and payable for an earlier period. Yes or No: Did the 2 conditions in B apply to your patient for an earlier period?
If yes, please provide the earlier date: Date (YYYY-MM-DD).
D. Consent to the release of medical information
In D, Yes or No: "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 they are below the age of consent in the jurisdiction where this form is completed, or because of a physical or mental condition."
If yes, please elaborate.
Signature
Sign on the Signature (Medical doctor or nurse practitioner) line and enter the Date (YYYY-MM-DD).
Your name, licence and practice
Select one: I am a medical doctor or I am a nurse practitioner.
Enter the Doctor's or nurse practitioner's name, the Licence or registration number and the Hospital or clinic of practice.
Enter the Apartment number, Street number and name, City or town, Province, territory or state, Postal or ZIP code, Country and Telephone number (999) 999-9999.
Practising outside Canada
Medical doctors, nurse practitioners and similar medical professionals outside Canada must also provide the following information: University where diploma obtained, Year diploma obtained (9999), City and country where diploma obtained.
Enter the Organization that oversees your license. Proof of my valid license is attached, or it can be verified at the following website.
I have the legal authority in my country of practice to make diagnoses, order and interpret tests, prescribe medications, and treat the critically ill patient referenced in this medical certificate.
More rules for Form SC INS5216B
Up to 26 weeks of benefits are available and can be claimed by one individual or shared among multiple caregivers.
Please complete the Medical Certificate for Employment Insurance Family Caregiver Benefits available at catalogue.servicecanada.gc.ca/content/EForms/en/Detail.html?Form=INS5242B if you think family caregiver benefits are more appropriate given the health status of your patient.
Common questions about Form SC INS5216B
Where do I file it?
The individual requesting EI compassionate care benefits must submit the medical certificate at the same time as the Authorization to Release Medical Information for Employment Insurance Compassionate Care and Family Caregiver Benefits form to Service Canada.
When is this form not the right one?
If the patient does not have a significant risk of death within 26 weeks but does require care or support, caregivers may be eligible for El family caregiver benefits.
Sources
[1] Form SC INS5216B (2025-01-006), Medical Certificate for Employment Insurance Compassionate Care Benefits, Service Canada (the Official source link on this page).