AUTHORIZATION FORM FOR PROSTHETIC
APPLIANCES AND DURABLE MEDICAL EQUIPMENT
P. O. BOX 1610 Windsor, Ontario N9A 0B7
To the Patient: The details requested below are mandatory in order for RBC Life to determine our liability with respect
to this request. For prior approval, please forward this form to the address indicated. A response letter outlining our
liability will be forwarded to the patient promptly. Our decision is not intended to interfere with or reflect upon the
course of treatment recommended by your doctor. Failure to request pre-approval may result in a denial of your claim.
Attn: EHS Department
CUSTOMER SERVICE CENTRE
1-855-264-2174
Fax 1-855-612-3031
Patient's Name
Date of Birth
/ /
Address Plan Member ID
Telephone No.
E-mail Address
Do you have any other Group Insurance coverage that may include these services as benefits?
If Yes, please provide Insurance Company name
If other coverage is RBC Life, indicate Plan Member ID
Yes No
SECTION II - MUST BE COMPLETED IN FULL BY PHYSICIAN
1) I, as the attending Physician, hereby prescribe the following prosthetic appliance(s) and/or medical equipment for the above named patient.
(Please include specifications when available.)
(A) Estimated Cost
(required)
(A)
(B) (B)
(C) (C)
(D) (D)
(E) (E)
2) Condition of Patient: Acute Chronic Palliative
3) Duration of Need: Weeks Months Year(s) Lifetime
4) Diagnosis (Please be specific):
5) For Hospital Beds only: Please indicate the hours or percentage of time in bed:
6) For Viscosupplementation only. Indicate left or right knee. Left Right
7) Please indicate why a standard item is not sufficient and a custom is required?
8) For TENS only: Please indicate if patient is currently receiving chiropractic or physiotherapy treatments or both (within last 6 months)?
Chiropractor Physiotherapy Both Neither
9) Is prescribed item a replacement? Yes No If Yes, give reason
10) Has application been made for Government funding? Yes No Not Applicable
If No, give reason
11) Is the device(s) and/or medical equipment required: as a result of a work related injury? Yes No
As a result of a motor vehicle accident? Yes No for sports purposes only? Yes No
Date( ) Specialist()G.P.Physician's Signature
Physician's Phone Number Physician's Name (Please Print)
I am authorized by my spouse and/or dependents to disclose and receive information about them that is used for these purposes. I understand that this information may be seen by
the cardholder.
By signing this claim form and/or submitting actual receipts, I agree that the information provided is complete and accurate. I understand that the information provided by me to
RBC Life about myself and my dependents, will be used by RBC Life for claims adjudication and any other services necessary in the administration of our benefits which may
include the exchange of information with other parties to administer this benefit claim.
I further authorize RBC Life to obtain and exchange information with other parties, such as health practitioners or insurers, in order to confirm the accuracy of the submitted
claim(s) information. In the event of suspected fraudulent activity pertaining to claims submitted on behalf of myself and/or my dependents, I acknowledge and agree to the disclosure
of this information to relevant parties, such as the Plan Sponsor, regulatory and law enforcement agencies.
ALL CLAIMS MUST BE SUBMITTED WITHIN 12 MONTHS OF THE DATE OF SERVICE (unless otherwise stated in your benefit plan documentation).
THE COST, IF ANY, OF OBTAINING THIS INFORMATION IS AT THE EXPENSE OF THE PATIENT/PLAN MEMBER.
RBC - Authorization Form For Prosthetic Appliances and Durable Medical Equipment EN (Rev. 2018-12) MED
SECTION I - MUST BE COMPLETED IN FULL BY THE PATIENT / GUARDIAN
