Authorization to Release Medical Information for Employment Insurance Compassionate Care or Family Caregiver Benefits

This form is required to authorize a medical doctor or nurse practitioner to release medical information about a patient so that family members can receive Employment Insurance (EI) compassionate care or family caregiver benefits. The claimant must submit this form at the same time as the INS5242B: Medical Certificate for Employment Insurance Caregiver Benefits form, or the INS5216B: Medical Certificate for Employment Insurance Compassionate Care Benefits form.