Form Sc Isp-2502-A - Consent For Service Canada To Obtain Personal Information
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1
2Service
PROTECTED B (when completed)
Canada
Personal Information Bank ESDC PPU 146
GIVE THIS FORM TO YOUR PHYSICIAN
WITH THE MEDICAL REPORT
Consent for Service Canada to Obtain Personal Information
Service Canada is authorized under Section 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. 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 CPP legislation. 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 Bank (ESDC PPU 146).
Instructions for accessing this information are provided in the Info Source, a copy of which is located in Service
Canada offices or at:
Instructions:
- Complete Sections 1 and 2 of this form; and
- Give this form to your physician with the medical report.
Section 1 - Client Information
Social Insurance Number
Mr.
Mrs.
Miss
Ms.
First Name and Initial
Last Name
Mailing address (No., Street, Apt. No., P.O. Box or R.R.)
City
Province or Territory
Country (If other than Canada)
Postal Code
Telephone Number
Fax Number
Service Canada delivers Employment and Social Development Canada
programs and services for the Government of Canada.
SC ISP-2502-A (2015-04-09) E
1 of 2
Disponible en français
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