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Number INS5216B
Title Medical Certificate for Employment Insurance Compassionate Care Benefits
Purpose INS5216A: Have this form completed by the patient or their legal representative authorizing the medical doctor or nurse practitioner to complete the medical certificate for Compassionate Care benefits. INS5216B: Have this form completed by a medical doctor or nurse practitioner 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.
GroupEmployment Insurance
Important Information
Returning the Form

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Service Canada (SC)

Medical Certificate for Employment Insurance Compassionate Care Benefits
PDF: SC-INS5216B, 202 KB, printed on 3 pages (8.5 x 11)

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