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Authorization to Release a Medical Certificate

I authorize the patient's doctor or nurse practitioner to Release the patient's Medical information to ESDC and to all family members who are claiming EI Compassionate Care benefits. I am legally authorized to consent to Release this patient's Medical information. The patient is unable to consent to the Release of Medical information. I authorize my doctor or nurse practitioner to Release my Medical information to Employment and Social Development Canada (ESDC) and to all my family members who are claiming EI Compassionate Care CanadaPROTECTED WHEN COMPLETED - BAuthorization to Release a Medical Certificate for Employment Insurance Compassionate Care BenefitsPatient InformationLast nameGiven name(s)Date of birth (yyyy-mm-dd)Home addressApartment numberStreet number and nameCity or townProvince, territory or stateCountry Patient's signatureDate (yyyy-mm-dd)Signature of Patient's RepresentativeSC INS5216A (2017-12-008) ERepresentative's signatureService Canada delivers Employment and Social Development Canada programs and services for the Government of CanadaPage 1 of 1 Patient's SignatureORDate (yyyy-mm-dd)Phone numberRelationship to patientName of representative (please print)

Authorization to Release a Medical Certificate for Employment Insurance Compassionate Care Benefits. Patient Information. Last name Given name(s) Date of birth (yyyy-mm-dd) Home address. Apartment number. Street number and name City …

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Information and Instructions - Service Canada

catalogue.servicecanada.gc.ca

sending your Terminal Illness Application to Service Canada. The date Service Canada receives your application could affect when your benefit starts. Service Canada will help you pay for the cost of the Terminal Illness Medical Attestation by paying up to $85.00 directly to your doctor or nurse practitioner.

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Statutory Declaration of Legal Marriage - Service Canada

catalogue.servicecanada.gc.ca

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United States/Canada Agreement - Application for Canadian ...

catalogue.servicecanada.gc.ca

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catalogue.servicecanada.gc.ca

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catalogue.servicecanada.gc.ca

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nReasons beyond their Control - Service Canada

catalogue.servicecanada.gc.ca

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catalogue.servicecanada.gc.ca

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catalogue.servicecanada.gc.ca

2. Please explain the reasons for the delay in filing your request for reconsideration: (Attach additional pages if required). SECTION 6: OTHER PERSON OR INTERESTED PARTY (To be completed only if you are not a claimant or an employer) Signature. Date1. Are you submitting this request for reconsideration on behalf of a claimant or an employer ...

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Consent to communicate Information to an Authorized Person

catalogue.servicecanada.gc.ca

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AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR …

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Voluntary. Failure to sign the authorization form will result in the non-release of the protected health information. This form will not be used for the authorization to disclose alcohol or drug abuse patient information from medical records or for authorization to disclose information from records of an alcohol or drug abuse treatment program.

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wa.kaiserpermanente.org

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AUTHORIZATION FOR DISCLOSURE OF MEDICAL, Authorization, Medical, Kaiser