P.O. BOX 1610 WINDSOR, ONTARIO N9A 0B7
Attn: EHS Department
Customer Service Centre 1-855-264-2174
AUDIO CLAIM FORM
THIS CLAIM FORM MUST BE FILLED OUT FOR ALL PAY PLAN MEMBER CLAIMS
PATIENT PROVIDER
Plan Member IDTelephone No.Provider No.
Name Name
Street Address Street Address
Postal Code Province CityPostal Code Province City
For Ontario Residents:
To be Completed by the Patient/Guardian
A copy of the ADP form must accompany this claim. If this
is not an ADP claim, please explain why and provide a
copy of this audiogram.
NoYes 1) Are these services required due to a work related injury?
NoYes 2) Are these services required due to an automobile accident?
For All Other Provinces:
NoYes 3) Do you have any other audio coverage?
Provide copy of audiogram.
If yes, please provide insurance company name
If other coverage is RBC Life, indicate Plan Member ID
Hearing Aid recommended by: ENT Otolaryngologist
//Date of Service (pickup date)
ddmmyy
Audiologist Family Doctor
CHARGES
Name:
RIGHT AIDLEFT AID
TOTAL CHARGES TOTAL CHARGES
ACQUISITION COST
MOLD
OPTIONS (LIST)
DISPENSING FEE
SUBTOTAL
ADP/Provincial Plan
ALLOWANCE
TOTAL
REPAIR- MANUFACTURER
(COPY OF INVOICE
REQUIRED)
REPAIR- PROVIDER
OTHER: (i.e. Batteries, Returns)
(please provide name of above)
Diagnosis (reason for aid):
DESCRIPTION OF HEARING AID
RECEIVER TYPE (Please Check)
DigitalProgrammable Conventional
R-70735R-70910R-70410BTE
L-70730L-70900L-70400
R-70725R-70810R-70610ITE
L-70720L-70800L-70600
R-70710R-70925R-70510ITC
L-70700L-70920L-70500
R-70710CIC
L-70700
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.
THERE IS NO NEED TO ATTACH A RECEIPT IF THIS FORM
HAS BEEN COMPLETED AND IF THIS AREA HAS BEEN SIGNED.
PATIENT/GUARDIAN
ONLY COMPLETE THIS SECTION ON THE DATE OF PICKUP,
AND ONLY IF THIS FORM IS COMPLETED.
PATIENT/GUARDIAN
I UNDERSTAND THAT THE CHARGES LISTED IN THIS CLAIM
MAY NOT BE COVERED BY OR MAY EXCEED MY
AGREEMENT BENEFITS.
THE CHARGES LISTED ON THIS CLAIM HAVE BEEN PAID IN
FULL BY THE PLAN MEMBER. PLEASE PAY PLAN MEMBER
FOR ELIGIBLE CHARGES.
I HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS CLAIM
TO THE ABOVE NAMED PROVIDER AND AUTHORIZE
PAYMENT DIRECTLY TO HIM.
I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO
THE SUPPLIER FOR THE COST OF THOSE SERVICES. I
AUTHORIZE RELEASE OF THE INFORMATION CONTAINED
IN THIS FORM.
SIGNATURE OF PROVIDER SIGNATURE OF PATIENT /GUARDIAN SIGNATURE OF PATIENT /GUARDIAN
THE COST, IF ANY, OF OBTAINING THIS INFORMATION IS AT THE EXPENSE OF THE PATIENT/PLAN MEMBER.
ALL CLAIMS MUST BE SUBMITTED WITHIN 12 MONTHS OF THE DATE OF SERVICE (unless otherwise stated in your benefit plan documentation).
RBC - Claim Form for Audio EN (Rev. 2018-12) AUD
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