Medical Certificate for Caregiver Benefits

Medical Certificate for Employment Insurance Family Caregiver Benefits

Background Information

Employment Insurance (EI) Family Caregiver benefits provide temporary income support to eligible individuals who take time away from work to provide care or support to a critically ill or injured family member. Up to 15 weeks of benefits are available for the care of an adult and up to 35 weeks are available for the care of a child under the age of 18. Benefits are payable during a 52-week period from the date provided in section B of this form.

The claimant must submit a medical certificate attesting that the child or adult is critically ill or injured and requires the care or support of one or more family members. The medical certificate must be signed by a medical doctor or nurse practitioner. Only one medical certificate needs to be completed, even if 2 or more caregivers intend to claim benefits.

Definition of “critically ill”

For the purposes of these benefits, “critically ill” refers to someone whose baseline state of health has changed significantly and whose life is at risk as a result of illness or injury. In addition, they must require the care or support of one or more family members.

Definition of “care” and “support”

For the purpose of these benefits, “care” means all care that the patient needs because of their state of health, other than the care provided by a health care professional. “Support” means all psychological or emotional support that the patient needs because of their state of health.

Guidance for medical doctors and nurse practitioners

The benefits are not intended for situations where the patient has a medically managed chronic illness or a permanent disability with no immediate threat to their life. However, the benefits are available to claimants who care for a chronically ill or disabled patient who experiences an acute illness or injury that puts their life at risk.

You are asked to estimate for how long the critically ill patient will require care or support. You must provide a specific date. For example, if the patient will require care or support for 4 to 12 weeks, indicate a date 12 weeks from the date of onset on the medical certificate. Even though a patient may be considered critically ill for only a short period of time, their family member(s) can continue to receive benefits for as long as the patient requires their care or support, based on the date you provide or until the maximum number of weeks of benefits has been paid.

If the patient requires care or support for longer than expected, the caregiver(s) will need to submit a second signed medical certificate to continue to receive benefits. The information on the second certificate should be the same as the first, with an updated estimate of the period of time during which care or support will be required. A new change in the patient’s baseline state of health is not necessary in those circumstances.

Caregivers of patients who have a serious medical condition and a significant risk of death within 6 months may be eligible for EI Compassionate Care benefits. If you think that Compassionate Care benefits are more appropriate given the health status of your patient, please complete the medical available at: https://catalogue.servicecanada.gc.ca/apps/EForms/pdf/en/SC-INS5216B.pdf.

Caregivers may be eligible to receive Family Caregiver and Compassionate Care benefits consecutively for the same patient. If Family Caregiver benefits are paid first, all available weeks must be paid before the caregiver would be eligible for the Compassionate Care benefit.

PROTECTED WHEN COMPLETED - B

A. Patient

B. Based on my assessment, I certify that the 3 conditions listed below existed as of

- “Care” means all care that is required because of a patient’s state of health, other than the care provided by a health care professional;

- “Support” means all psychological or emotional support that is required because of a patient’s state of health.

Note: For purposes of the Family Caregiver benefits, the following definitions apply:

C. In my professional opinion, the patient will require the care or support of one or more family members until:

Note: A specific date must be provided.

D. In my professional opinion and to the best of my knowledge, the patient identified above is unable to consent to the release of medical information because they are below the age of majority, or because of a physical or mental condition.

This form must be completed by a medical doctor or nurse practitioner.

The Authorization to Release a Medical Certificate for Employment Insurance Family Caregiver Benefits is a separate form and will be provided by the individual requesting that you complete this medical certificate. This medical certificate and the Authorization to Release a Medical Certificate form must be submitted together when a claim for Family Caregiver benefits is made.

Contact Information

Medical doctors and nurse practitioners outside Canada must also provide the following information:

Select one: I am a medical doctor I am a nurse practitioner