INS5216B: EI Compassionate Care Medical Certificate

Caregivers who stop work to look after a family member at the end of life need this certificate for Employment Insurance compassionate care benefits. The doctor or nurse practitioner attests that the patient has a serious medical condition with a significant risk of death within 26 weeks and needs care or support. Up to 26 weeks of benefits can go to one caregiver or be shared among several, all on one certificate.

Who completes it

A medical doctor or nurse practitioner completes and signs the whole certificate, including whether the patient can consent to releasing medical information. The patient or their legal representative (a parent or legal guardian for a child) signs the separate INS5257 authorization, which the caregiver must present to you.

How to fill it in

Background information and guidance for medical doctors and nurse practitioners (page 1)

Read page 1 before completing the certificate. "Care" means all care the patient needs because of their state of health, other than care provided by a health care professional; "support" means the psychological or emotional support the patient needs. The guidance explains when the family caregiver certificate (INS5242B) fits better: a patient who needs care or support but does not have a significant risk of death within 26 weeks.

A. Patient last name, given name(s) and date of birth

Enter the name and date of birth (YYYY-MM-DD) of the person who needs end-of-life care, not the caregiver claiming benefits. The certificate does not ask for caregivers' names, because one certificate covers every caregiver who intends to claim. Check that the caregiver has also brought the INS5257 authorization signed by the patient or their legal representative.

B. Last examination and the two conditions

Give the date you last examined the patient, then answer yes or no to both statements: the patient has a serious medical condition with a significant risk of death within the next 26 weeks, and the patient requires the care or support of one or more family members over the next 26 weeks. The certificate attests to both. Compassionate care benefits are payable from the date in B or the week the certificate is signed.

C. Earlier period

Say whether the two conditions in B applied to your patient for an earlier period, and if so give that earlier date. The form notes that benefits are normally payable from the date in B or the week the certificate is signed, but in some situations may be requested and paid for an earlier period, so an accurate earlier date can matter to the caregivers.

D. Ability to consent

Say whether, in your professional opinion, the patient is unable to consent to the release of medical information because they are below the age of consent where the form is completed, or because of a physical or mental condition, and elaborate if yes. This records whether the patient or a legal representative should sign INS5257; for a child, a parent or legal guardian signs.

Signature, date and practitioner details

Sign and date the certificate, then select medical doctor or nurse practitioner and give your name, licence or registration number, hospital or clinic of practice, address and telephone number. Practitioners outside Canada also give the university, year, city and country of their diploma, the organization overseeing their licence, proof of licence or a verification website, and confirm their legal authority to diagnose, order and interpret tests, prescribe and treat.

Common mistakes

Completing a certificate for each caregiver: one certificate is enough, and if several arrive the first valid one fixes the 52-week window.
Using this form when there is no significant risk of death within 26 weeks; the family caregiver certificate (INS5242B) may fit better.
Completing the certificate without the patient's INS5257 authorization, which the caregiver must present to you and submit at the same time as the certificate.
Skipping section D, which must record whether the patient can consent to the release of medical information.
For practitioners abroad, omitting diploma and licensing details or proof of a valid licence, which page 3 requires.

Submitting and payment

How to submit it: Give the certificate to the caregiver, who must submit it at the same time as INS5257 by uploading both in My Service Canada Account, mailing them or dropping them off at a Service Canada location. The documents can follow the online application, which the caregiver should file as soon as possible after stopping work.
Who pays: Neither the certificate nor Service Canada's caregiving benefit pages describe any payment to the doctor or nurse practitioner for completing it.

Good to know

Benefits can be received during the 52 weeks after the date the patient is certified as needing end-of-life care, so the date in section B, or an earlier date in section C, matters.
Caregivers can be any family member, broadly defined, or someone the patient considers like family; an unrelated caregiver needs the patient's signed Family Member Attestation (INS5223).
For patients receiving care outside Canada, a doctor or nurse practitioner in that country completes the certificate and adds diploma, licensing and proof-of-licence details on page 3.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Certificate for Employment Insurance Compassionate Care Benefits

Certificat médical pour des prestations de compassion de l'assurance-emploi

Official page PDF Version française

Fill it with Vero

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.

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How this list is checked

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

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who can sign the EI compassionate care medical certificate?

Only a medical doctor or nurse practitioner. If the patient is receiving care outside Canada, a doctor or nurse practitioner in that country, or a person authorized by that country with substantially similar qualifications, can sign. They add where and when they obtained their diploma, the organization overseeing their licence and proof of a valid licence.

Does each caregiver need a separate certificate?

No. Only one medical certificate is needed even if two or more caregivers intend to claim, and the 26 weeks of benefits can be shared among them. If more than one certificate is submitted, the first valid one determines the start and end dates of the 52-week period in which benefits can be paid.

Can compassionate care benefits start before the date I examined the patient?

Possibly. Benefits are normally payable from the last-examination date in section B or the week the certificate is signed, but the form says that in some situations they can be requested and paid for an earlier period. Section C asks whether both conditions applied earlier and, if so, for the earlier date.

What if the patient is not expected to die within 26 weeks?

Then compassionate care benefits don't fit. If the patient is critically ill or injured, meaning their baseline health has changed significantly and their life is or was at risk, caregivers may qualify for EI family caregiver benefits instead, which use a different certificate, INS5242B.