Patients claiming Employment Insurance sickness benefits need a signed certificate showing they can't work for medical reasons and for approximately how long. This one-page form is Service Canada's version: the practitioner gives the dates of incapacity and signs. The patient submits it if Service Canada asks, with or after the application, and otherwise keeps it for 6 years.
Section 1 holds the patient's details, and the treating practitioner completes and signs Section 2. Eligible practitioners are medical doctors and nurse practitioners, and, within their field, chiropractors, podiatrists, optometrists, psychologists, dentists and midwives, plus registered nurses in isolated areas when a doctor is unavailable.
Confirm the patient's last and first name, social insurance number, date of birth (YYYY-MM-DD), address and telephone number are filled in; the address block accepts a province, territory or state, a postal or ZIP code and a country. The patient may need to hand this certificate to Service Canada months or years later, so the identifying details should be complete and legible.
The attestation reads that, in your opinion, the patient is unable to work for medical reasons from one date up to and including another, both in YYYY-MM-DD format. The first date is when the incapacity began; the second is the expected end. When a practitioner uses their own certificate instead, Service Canada asks for the same essentials: the start date and the expected duration, if known, of the incapacity due to illness, injury or quarantine. The form has no diagnosis field.
Print your name, your speciality and your licence or registration number. The speciality matters because Service Canada requires the illness or injury to be within the certifying practitioner's field of expertise, which limits chiropractors, podiatrists, optometrists, psychologists, dentists and midwives to conditions in their own field. Registered nurses can sign only in isolated areas when a doctor is unavailable.
Add your practice address, then sign and date the certificate. Service Canada accepts a handwritten, electronic or stamped signature, and the practitioner should be practising in Canada or the United States. Hand the signed form to the patient, who keeps it unless Service Canada asks for it. Service Canada does not reimburse the certificate, so any fee is charged to the patient.
Download the current version from the source each time; forms change without notice.
Medical Certificate for Employment Insurance Sickness Benefits
Certificat médical pour les prestations de maladie de l'assurance-emploi
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
Sources for this guide
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The treating medical practitioner: a medical doctor or nurse practitioner, or a chiropractor, podiatrist, optometrist, psychologist, dentist or midwife for conditions within their field. A registered nurse can sign in isolated areas when a doctor is unavailable. The practitioner should be practising in Canada or the United States.
No. Service Canada accepts the practitioner's own certificate if it is readable, carries the practitioner's letterhead or official stamp, names the patient, gives the start date and the expected duration (if known) of the incapacity due to illness, injury or quarantine, and has a handwritten, electronic or stamped signature.
No. Service Canada does not reimburse the certificate. The practitioner may charge the patient for completing it, whether on form INS5140 or on the practitioner's own certificate, and Service Canada will not refund that fee to the patient.
Up to 26 weeks. The certificate gives the date the patient became unable to work and the date up to which they are expected to be off. To qualify, patients also need 600 insured hours in the 52 weeks before the claim and a drop of more than 40% in regular weekly earnings for at least one week.