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Isp 2502 A

This document is a consent form for Service Canada to obtain personal information about an individual to determine eligibility for Canada Pension Plan disability benefits or help assess incapacity. It lists medical professionals, facilities, educational institutions, employers, insurance plans and government agencies that Service Canada may contact. The individual can either give consent for Service Canada to obtain information from these sources, or not give consent, in which case Service Canada will make a decision based on available information and may stop or require the individual to provide necessary information.

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103 views2 pages

Isp 2502 A

This document is a consent form for Service Canada to obtain personal information about an individual to determine eligibility for Canada Pension Plan disability benefits or help assess incapacity. It lists medical professionals, facilities, educational institutions, employers, insurance plans and government agencies that Service Canada may contact. The individual can either give consent for Service Canada to obtain information from these sources, or not give consent, in which case Service Canada will make a decision based on available information and may stop or require the individual to provide necessary information.

Uploaded by

S
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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PROTECTED B (when completed)

Give this Form to your Physician or Nurse


Practitioner with the Medical Report

Consent for Service Canada to Obtain Personal Information

Service Canada is authorized under sections 44, 68 and 69 of the Canada Pension Plan (CPP) Regulations to
receive personal (medical and non-medical) information about you to decide if you qualify or continue to
qualify for CPP disability benefits. Service Canada is also authorized under sections 55.3 and 60 (8) to (11) of
the Canada Pension Plan and section 28.1 of the Old Age Security Act (OAS Act) to receive personal
(medical and non-medical) information about you to help in the assessment of incapacity.

Your consent to permit Service Canada to obtain this information is necessary, should Service Canada need
this information from persons and organizations listed on the following page.

Protecting your privacy:

Service Canada cannot give your personal information to any person or organization without your written
consent, except where authorized by the Department of Employment and Social Development Act. Under the
Privacy Act, you (or your authorized representative) have the right to request a copy of the information in your
file and to request correction(s) to that information. Your personal information is retained in Personal
Information Banks (ESDC PPU 116, 146 & 175).

Instructions for accessing this information are provided in the Info Source, a copy of which is located in
Service Canada offices or at: www.infosource.gc.ca.

Instructions:
- complete Sections 1 and 2 of this form; and
- give this form and the medical report to your physician or nurse practitioner.

Section 1 - Information about you


Social Insurance Number
Optional: Mr. Mrs. Miss Ms.
535074678

First name Middle name Last name(s)


Spencer C

Mailing address (no., street, apt, PO Box, RR) City/Town


1207 Booth Ave Barrie

Province/Territory Country (if not Canada) Postal code


ON Canada L4M 1A4

Telephone number Alternate telephone number


(705)-304-0235 705-896-4690

Service Canada delivers Employment and Social Development Canada


programs and services for the Government of Canada

SC ISP-2502-A (2021-12-15) E 1/2 Disponible en français


Social Insurance Number: PROTECTED B (when completed)

Consent to obtain personal information

I give Service Canada my consent to obtain personal information about me that would help determine if I
qualify or continue to qualify for CPP disability benefits or help in the assessment of incapacity as under the
CPP or the OAS Act. For this reason, Service Canada may contact any of the following persons and
organizations if necessary:
- medical doctors, nurse practitioners, consultant - voluntary organizations
specialists, or health-care professionals
- federal, provincial, territorial, or municipal
- medical facilities or hospitals government departments and agencies
- educational institutions or other vocational - employers, former employers
agencies
- my accountant or book-keeper for information - provincial or territorial workers' compensation
on self-employment boards
- administrators of insurance plans (long-term - financial institutions - for address updates only
care facilities or retirement homes, medical - employees - for cases of self-employed persons
records storage facilities)

Section 2 - I give my consent or I do not give my consent


Note: Failure to select an option below could cause a delay in processing your application or
determining your benefit amounts.
I give my consent to Service Canada to obtain medical and other personal information about me
from all persons and organizations listed above. I understand that this information may help
determine if I qualify or continue to qualify for CPP disability benefits.
I do not give my consent to Service Canada to obtain medical and other personal information
about me from all persons and organizations listed above.

I understand that if I do not give my consent, Service Canada:

- will make a decision based on the available information on my file;


- may stop paying me the benefits if I am already receiving them; and
- can require that I provide the necessary information.

Signature of applicant / authorized representative Date (YYYY-MM-DD)


20220607

To be completed by a witness only if the applicant signs with a mark (e.g. X).
I have read the contents of this section to the applicant, who appeared to fully understand them and who
made their mark in my presence.
First name of witness (print) Middle name Last name(s) Telephone number
E (705)-304-0235

Signature of witness Date (YYYY-MM-DD)


20220607

This signed consent is valid for up to 3 years unless you cancel it in writing. Service Canada requires your
original signature, but we as well as the third party may accept a photocopy or fax of this completed form as it is
as valid as the original when requesting personal information from the persons and organizations listed above.

SC ISP-2502-A (2021-12-15) E 2/2

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