Fillable ATTENDING PHYSICIANS HOME CARE CLAIMS STATEMENT (RBC Insurance)

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ATTENDING PHYSICIANS HOME CARE CLAIMS STATEMENT (RBC Insurance)

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The ATTENDING PHYSICIANS HOME CARE CLAIMS STATEMENT (RBC Insurance) form is 2 pages long and contains:

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  • 8 check-boxes
  • 61 other fields

Country of origin: CANADA
File type: PDF

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ATTENDING PHYSICIANS HOME CARE CLAIMS STATEMENT
Other (specify)
_______________________________________________________________________________________________
RBC Life Insurance Company
4435 Stn A
Toronto, ON M5W 5Y8
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 t o
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
(a) Date home care commenced (if applicable) __________ Month ________ Day, _________ Year
(c) Type of care required
and frequency of visits by the Provider _________________________________________
(d) Date
home care terminated ___________ Month ________Day, _________ Year
(e) 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 ________________________________________________
™Trade-marks of Royal Bank of Canada. RBC Life Insurance Company, licensee of trade-marks
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______________________________________________________________________________________
______________________________________________________________________________________
controlling
b
ladder or bowel functions
If “Yes”, by what means?
TYPE OF TREATMENT
(a) Med
ication
s Dosages
(b) Describe Therapy and projected duration of treatment program
(c) Type of surgery
(d) Date of surgery (if applicable)
PHYSICAL IMPAIRMENT
Is patient Ambulatory Bed confined House confined Hospital confined?
Does the patient currently need another person’s help in performing any activities of daily living, such as
bathing dressing toileting eating walking indoors transferring from
bed to
chair
taking medications as prescribed ?
CARDIAC (if applicable)
(a)
Functional capacity:
Class 1 (no limitation) Class 2 (slight limitation) Class 3 (marked limitation)
Class 4 (complete limitation)
(b) Blood Pressure latest visit (systolic/diastolic) _______________________________________________
(c) Last METS rating: Date of test: ___________________
VISUAL IMPAIRMENT (if applicable)
(a) What was vision at latest observation with glasses?
(b) What was vision at latest observation without glasses?
(c)
Vision can be restored in whole or in part:
Yes No
PROGNOSIS
Please indicate date when patient will again be able to perform any of the above activities of daily living
DO YOU BELIEVE THE PATIENT IS COMPETENT TO ENDORSE CHEQUES AND DIRECT THE USE OF
PROCEEDS THEREOF?
Yes No
REMARKS
Physician’s Name ____________________________________ Certified Specialist In _____________________
Address____________________________________________________ Telephone Number________________
Date ______________________________ M.D. Signature ___________________________________________
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ATTENDING PHYSICIANS HOME CARE CLAIMS STATEMENT (RBC Insurance)

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Completed 21 May 2021

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