INS5242B: EI Family Caregiver Medical Certificate

Family members who take time off work to care for a critically ill or injured adult or child need this certificate for Employment Insurance family caregiver benefits. The doctor or nurse practitioner certifies three conditions and gives a specific date until which care or support is expected. Benefits last up to 15 weeks for an adult or 35 weeks for a child under 18, paid within 52 weeks of the date in section B.

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)

Page 1 defines what you certify. "Critically ill" means the baseline state of health has changed significantly and life is or was at risk as a direct or indirect result of illness or injury. "Care" is all care needed because of the patient's health, other than care from a health care professional; "support" is psychological or emotional support. The guidance also says the benefit is not for a medically managed chronic illness or permanent disability with no immediate threat to life.

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

Enter the patient's names and date of birth (YYYY-MM-DD). Age on the first day of the period you certify decides which benefit applies: up to 15 weeks for an adult (18 or older) or up to 35 weeks for a child under 18. On an extension certificate, the details in sections A and B must match the first certificate.

B. Date the 3 conditions existed

Give the date as of which you certify all three conditions. It can be the date you examined the patient, an earlier date according to the patient's file, or the date you sign; it helps set when caregivers can start receiving benefits, which are paid within the 52 weeks after it. Then answer yes or no: the patient's life is or was at risk as a result of illness or injury; there is or was a significant change in baseline health; the patient requires care or support from one or more family members.

C. Care or support needed until

Give a specific date until which you expect the patient to need the care or support of family members. The form requires a date, and Service Canada's guidance says it cannot be unknown or indefinite. Benefits are paid for as long as care is needed, based on this date, until the maximum weeks are used, and family members can keep receiving benefits while the patient recovers.

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

Writing unknown or indefinite in section C: a specific date is required, and the caregiver can submit a second certificate if care lasts longer.
Issuing an extension whose sections A and B differ from the first certificate; they must match, with only the new end date changing.
Certifying a stable, medically managed chronic illness or permanent disability with no immediate threat to life, which the benefit is not intended for.
Completing a certificate for each caregiver, or separate adult and child versions; one INS5242B covers all caregivers and both age groups.
Signing without the patient's INS5257 authorization, which the caregiver must present to you and submit at the same time as the certificate.

Submitting and payment

How to submit it: Give the certificate to the caregiver, who submits 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

If the patient has a serious medical condition with a significant risk of death within 26 weeks, the compassionate care certificate (INS5216B) may be more appropriate.
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 Family Caregiver Benefits

Certificat médical pour les prestations pour proches aidants 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

What counts as critically ill for EI family caregiver benefits?

Someone whose baseline state of health has changed significantly and whose life is or was at risk from illness or injury. It includes patients who can't meet their basic personal needs because of the illness or injury, and chronically ill or disabled patients with an acute, life-threatening event, but not a medically managed chronic illness or permanent disability with no immediate threat to life.

What if the patient needs care longer than the date I gave?

The caregiver submits a second signed certificate. Sections A and B must match the first certificate, with a new date in section C for how much longer care or support is needed. The patient's baseline health does not need to change again to extend the date, but benefits still stop at the maximum number of weeks.

Is there a separate certificate for a critically ill child?

No. INS5242B covers both the family caregiver benefit for adults, up to 15 weeks, and the benefit for children, up to 35 weeks. The patient counts as a child if under 18 on the first day of the period you certify. Only one certificate is needed even when several caregivers will claim.

Can I write unknown for how long care is needed?

No. Section C needs a specific date, and Service Canada's guidance says it cannot be unknown or indefinite. Estimate how long care or support will be needed. Family members can keep receiving benefits while the patient recovers, even if the critical phase is short, and a second certificate can extend the date.