P. O. BOX 1610
Windsor, Ontario N9A 0B7
Attn: EHS Department
Customer Service Centre 1-855-264-2174
CLAIM FORM FOR CUSTOM FOOT ORTHOTICS/FOOTWEAR
To the Patient: The details requested below are mandatory in order for RBC Life to determine our liability with respect to this request.
PATIENT PROVIDER
Plan Member IDTelephone No. Provider No.
/ /
Date of Birth
( )
Name Name
Street Address Address
Postal CodeProvince CityPostal CodeProvince City
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
THIS SECTION MUST BE COMPLETED IN FULL BY THE DISPENSING AND/OR TREATING PHYSICIAN / CHIROPODIST / PODIATRIST /
PEDORTHIST / ORTHOTIST.
1. I hereby prescribe/provide the following for the above named patient:
Custom Foot Orthotics Orthopedic Shoes*
* Please provide make and model of orthopedic shoes if applicable
2. Diagnosis (please be specific):
3. Are the device(s) 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
If the Claim is for Custom Foot Orthotics, the following is also required:
1. Copy of diagnostic measures test results:
Biomechanical Examination or Gait Analysis Other
2. Identify casting technique. Must create 3D volumetric model of patient’s foot.
Subtalar Neutral Cast( i.e. Plaster of Paris) Semi-Weight Bearing Cast (i.e. Foam Cast)
3D Laser Scan Other, please indicate
3. Copy of the lab invoice showing the raw materials used to construct the orthotic and the costs associated/ incurred in the manufacturing process.
The prescriber must sign in this box or attach the prescription.
Date
Name of Physician / Chiropodist / Podiatrist (Please Print)
Physician Chiropodist Podiatrist Other
Signature Phone No. ( _____ )
TREATMENT DESCRIPTION DATE OF PICKUP CHARGES $
1. $
2. $
3. $
DAY MOYR
I CERTIFY THAT THE TREATMENT DESCRIBED ABOVE WAS PERFORMED BY ME AND ALL INFORMATION PROVIDED ON THIS FORM IS ACCURATE.
Signature of Provider Accreditation
Registered No.
THE PLAN MEMBER HAS PAID THE CHARGES LISTED ON
THIS CLAIM IN FULL. PLEASE REIMBURSE PLAN MEMBER
DIRECTLY.
I CERTIFY THAT THE ORTHOTICS HAVE BEEN PICKED UP AND ARE IN MY
POSSESSION AND HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE
PROVIDER NAMED ABOVE.
Signature of Provider
Signature of Patient Date
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).
RBC - Claim Form for Custom Foot Orthotics EN (Rev. 2018-12) CFO
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