What the INS5140 is for
EI sickness benefits replace part of a worker’s income for up to 26 weeks when they can’t work for medical reasons. To qualify, the patient needs 600 insured hours in the 52 weeks before the claim, a drop of more than 40% in regular weekly earnings, and a medical certificate. The INS5140 is Service Canada’s version of that certificate. You attest that the patient is unable to work for medical reasons over a stated period.
Service Canada assesses the hours and earnings. Your part is only the medical period, and the form has no diagnosis field. The INS5140 is often mixed up with a CPP disability medical report, the ISP-2519, which is a long report for a severe and prolonged disability, and with employer or insurer sick notes, which follow their own rules.
Who completes it
Section 1 holds the patient’s information: name, social insurance number, date of birth, address, and phone. The medical practitioner completes and signs Section 2. Doctors, nurse practitioners, chiropractors, podiatrists, optometrists, psychologists, dentists, and midwives can all sign for conditions within their field, and a registered nurse can sign in isolated areas where no doctor is available.
The chart rarely holds the patient’s social insurance number, so ask the patient for it or leave it for them to add before they keep or send the certificate.
How to fill in Section 2
The period of incapacity
Enter the date the patient became unable to work for medical reasons and the date the period runs up to and including. Use the date the patient actually stopped work for the condition, which may come before the visit, if the record supports it. For the end date, give your best estimate of the expected duration. Service Canada asks for approximately how long the patient will be unable to work.
Practitioner details and signature
Print your name, specialty, licence or registration number, and address, then sign and date the certificate. Service Canada accepts a handwritten, electronic, or stamped signature.
Common reasons it’s delayed
- No end date, or an open-ended period such as “until further notice”.
- A start date after the patient’s last day of work with no explanation.
- A practitioner certifying a condition outside their field.
- Missing licence or registration number.
- A clinic note used in place of the INS5140 without letterhead, a stamp, or the expected duration.
Submitting and who pays
The patient applies for EI sickness benefits and should apply soon after stopping work, since applying more than four weeks after the last day of work may cost them benefits. Service Canada may ask for the certificate with the application, and the patient can upload it to My Service Canada Account, mail it, or drop it off. If it isn’t requested, the patient keeps it for six years. Service Canada doesn’t pay for the certificate, so any fee is charged to the patient.