P.O. BOX 1610
WINDSOR, ONTARIO N9A 0B7
Attn: EHS Department
Customer Service Centre 1-855-264-2174
Fax 1-855-612-3031
AUTHORIZATION FORM FOR CUSTOM BRACES
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.
SECTION I - MUST BE COMPLETED IN FULL BY THE PATIENT/GUARDIAN
/ /Date of Birth Patient Name
Plan Member IDAddress
Telephone No.
E-Mail Address
Do you have any other Group Insurance coverage that may include these services as benefits? Yes No
If Yes, please provide Insurance Company name
If other coverage is RBC Life, indicate Plan Member ID
SECTION II - MUST BE COMPLETED IN FULL BY TREATING PHYSICIAN
I, as the attending physician, hereby prescribe the following custom brace for the above named patient. (Please include
specifications when available.)
1.
(A) Type Of Brace:
(B) Left Right Bilateral
(C) Estimated cost:
Condition of Patient: Acute Chronic2.
Duration of Need: Week(s)
Month(s) Year(s) Lifetime 3.
Diagnosis (Please be specific):
4.
Past Treatment: Physio
# of Treatments Surgery Medications X-rays5.
Degree of joint space: Past/Future Loss
NA6.
Specify medically why a custom brace is necessary as opposed to a standard brace.7.
Was brace shown to patient and costs provided? Yes No8.
Is the prescribed item a replacement? Yes If Yes, give reason No9.
Has application been made for Government funding? Yes No10.
If No, give reason Not Applicable
Is the device(s) and/or medical equipment required:11.
NoYe s - As a result of a work related injury?
NoYe s - A motor vehicle accident?
NoYe s - For sports purposes only?
Date
Physician's Signature
Physician's Telephone 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 Custom Braces EN (Rev 2018-12)
KNEEB
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