RBC Life Insurance Company
4435 Stn A
Toronto, ON M5W 5Y8
ATTENDING PHYSICIANS FACILITY CARE CLAIMS
STATEMENT
PATIENT NAME _____________________________________________ POLICY NUMBER ___________________
I hereby authorize the release
to my insurer any information requested with respect of this claim.
DATE _________________________________ SIGNATURE OF PATIENT _________________________________
PHYSICIAN’S STATEMENT
This form has been specifically designed with the physician in mind. By being comprehensive, it will hopefully reduce the physician;s
administrative workload. Please complete the sections relating to your p atient and stroke out the non-applicable areas. In order
to help the claimant, sufficient details of History, Investigation, Findings and Treatment are essential. This form may be mailed
directly to the insurer or given to the patient at the physician’s discretion.
HISTORY
(a) When did symptoms first appear or accident happen? _________ Month ________Day __________Year
(b) Date facility care recommended __________ Month ________ Day _________ Year
(c) Level
of care required __________________________________________________________________________
(d) Full
names
of other treating physicians
_____________________________________________________________
DIAGNOSIS
(a) Primary
(b) Date of Diagnosis ___________________________
(c) Secondary (if applicable)
(d) Date of Diagnosis ___________________________
(e) Subjective Symptoms
(f) Objective findings (including results of current X-rays, E.K.G.’ s or any other special tests)
TREATMENT
(a) Date of first treatment
(b) Date of latest visit
(c) Is patient following recommended treatment program?
Yes No
(d) Dates of all treatment
(e) Frequency: Weekly Monthly Other (specify) ____________________________________________
™Trade-marks of Royal Bank of Canada. RBC Life Insurance Company, licensee of trade-marks.
