CHRONIC CARE / ALTERNATE LEVEL OF CARE
CLAIM FORM
1) This form must be completed in full by a Hospital Official and should be forwarded to our office (Attn: Hospital
Claims Department) after the month for which the co-payment fee applies.
How to Claim:
2) An assessment to determine eligibility for a reduced rate must be completed by a Hospital Official and copies of
the results MUST be forwarded with the initial claim. The Hospital will have a supply of the assessment forms as they
are provided by the Ministry of Health directly to the Hospital.
Name of Facility
Address
Plan Member ID
//Birth Date Patient's Surname Given Name
Day MonthYear
Date of Admission to: Chronic Care ALC
Is this placement expected to be permanent for rehabilitation purposes only.
Ye s N o Is this claim the result of a Motor Vehicle Accident?
Ye s N o Are these benefits provided by any other insurer?
If Yes, please provide insurance company name
If other coverage is RBC Life, indicate Plan Member ID
Account for period from to
Monthly Co-payment Charge $ OR Rate per day $ X days = $
(Rate per day calculation is for partial month billings only.)
Type of Accommodation occupied: Standard Semi-Private Private
If patient occupied a Semi-Private room, indicate applicable differential charge in addition to the
co-payment: $ X days = $
Direction to Pay
If payment is to be issued directly to the facility, please indicate Provider Number
If payment is to be issued to plan member, please indicate the full mailing adress to which the cheque should be sent.
Certification of Hospital
We certify that the patient named above has resided in a Chronic Care/ALC bed for period billed. An assesment to determine eligibility for a reduced rate
(refer to Ministry of Health Rules and Guidelines) has been conducted and the charges indicated above take the assessment results into account.
Signature of Hospital OfficialDate
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.
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).
Send form to: RBC Life Insurance Company
P.O. BOX 1603, Windsor, Ontario N9A 0B6
CUSTOMER SERVICE CENTRE 1-855-264-2174
RBC - Claim Form for Chronic Care-Alternate Level of Care EN Rev 2018-12
CHRON
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