AUTHORIZATION FORM FOR OXYGEN
EQUIPMENT AND SUPPLIES
To the Patient: The details requested below are mandatory in order for RBC Life to determine our liability with respect to this request for oxygen
equipment/supplies. For prior approval, please forward this request to the address indicated below. Failure to submit this authorization for pre-approval
may result in a denial of your claim.
SECTION 1 - PLAN MEMBER INFORMATION
EMAIL ADDRESS
PLAN MEMBER ID
TELEPHONE NUMBERSURNAME FIRST NAME
DATE OF BIRTH
_______ / _______ / _______ AGE _________
ADDRESS
CITY PROVINCE POSTAL CODE
Do you have any other group insurance coverage that may include these services as benefits? Ye s No
If Yes, please provide Insurance company’s name
If other coverage is with RBC Life, indicate other RBC Life Plan Member ID
SECTION 2 - MUST BE COMPLETED IN FULL BY THE PHYSICIAN
PLEASE ATTACH COPIES OF ARTERIAL BLOOD GASES AND/OR OXIMETRY READINGS WITH THIS REQUEST.
1. This application is: Renewal New. If new, what is the set up date?
2. Diagnosis (please be specific):
3. Has an application been made to the Ministry of Health for Funding? Yes No
If No, please provide reason.
(If application has been made and funding denied, please attach their denial letter.)
4. Method of Supply:
concentrator (including back-up and portable cylinders)
cylinder (compressed oxygen for stationary and/or portability)
5. Name of Oxygen Vendor (if available)
6. Is oxygen required: As a result of a work related injury? Yes No
As a result of a motor vehicle accident? Yes
No For sports purposes only? Yes No
PLEASE ATTACH COPIES OF ARTERIAL BLOOD GASES AND/OR OXIMETRY READINGS WITH THIS REQUEST.
()G. P. ( ) Specialist
Physician's Signature Date
Physician's Name (please print) Physician's Phone Number
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.
Once completed, please return form as well as any other information to:
RBC Life
Attn: EHS Department
P. O. BOX 1610
Windsor, Ontario N9A 0B7
Completed Forms can also be faxed : 1-855-612-3031
Authorization Form For Oxygen Equipment and Supplies EN (Rev. 2018-12) OX
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