P.O. BOX 1613, Windsor, Ontario N9A 0B8
Attn: In Home Nursing/EHS Department
Customer Service Centre 1-855-264-2174
AUTHORIZATION FORM FOR IN HOME SUPPORT SERVICES OF A
REGISTERED NURSE, REGISTERED PRACTICAL
NURSE/LICENSED PRACTICAL NURSE, PERSONAL SUPPORT
WORKER/HOME SUPPORT WORKER
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 refect upon
the course of treatment recommended by your doctor. Failure to request pre-approval may result in a denial of your
SECTION I - MUST BE COMPLETED IN FULL BY THE PATIENT/GUARDIAN
_______/_______/_______Date of BirthPatient's Name
Plan Member IDAddress
E-Mail Address ________________________________________ Telephone No. ______________________
Telephone No. _______________________ Contact Person_______________________
Do you have any other Group Insurance coverage that may include these services as benefts? Yes No
If yes, please provide Insurance Company name __________________________________________________________________________
If other coverage is RBC Life, indicate Plan Member ID ______________________________________
Are these services required due to a work related accident? Yes No Date of injury_____________________
Are these services required due to a motor vehicle accident? Yes No Date of accident_____________________
SECTION II - MUST BE COMPLETED IN FULL BY THE PHYSICIAN/NURSE PRACTITIONER
I, as the attending Physician/Nurse Practitioner, hereby authorize services for R.N. _______ RPN/LPN _______ 1)
PSW/HSW _______ for the above named patient.
Patient diagnosis (please be specifc)
Special care and treatment to be rendered (indicate duties to be performed, including any complications or extenuating
circumstances, special equipment that needs to be monitored, medications to be administered and whether they are being
administered on a regular or a PRN basis orally or by injection, intramuscular or subcutaneous). PLEASE BE SPECIFIC.
Starting date of care:4)
Expected duration of need for these services:
Week(s) Month(s) 1 Year 5)
Number of hours PER DAY that these services are required: RN
Number of days per week: RN
Are these services required in the patient's home? Yes
Are the services being requested in addition to those being provided under any Government funded programs (i.e. Ontario -
Home Care)? Yes
No If yes, please indicate what services are being provided. If no, please specify reason.
Hours per day Level of Care (RN/RPN/LPN, PSW/HSW) Name of Agency
Case Manager Case Manager’s Telephone No.
DatePhysician/Nurse Practitioner’s Signature
Physician/Nurse Practitioner’s Phone No Physician's/Nurse Practitioner 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 benefts which may include the exchange of information
with other parties to administer this beneft claim.
I further authorize RBC Life to obtain and exchange information with other parties, such as health practitioners or insurers, in order to confrm 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 RECEIVED WITHIN 12 MONTHS OF THE DATE OF SERVICE (unless otherwise stated in your beneft plan documentation).
THE COST, IF ANY, OF OBTAINING THIS INFORMATION IS AT THE EXPENSE OF THE PATIENT/PLAN MEMBER.
Authorization Form For In Home Support Services of a Registered Nurse, Registered
Practitioner Nurse/Licensed Practical Nurse, Personal Support Worker/ Home Support
Worker -EN (Rev. 2015-09)
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