CLAIM FORM FOR IN HOME SUPPORT SERVICES OF A REGISTERED
NURSE/RN, REGISTERED OR LICENSED PRACTICAL NURSE/RPN/LPN,
PERSONAL SUPPORT WORKER/PSW, HOME SUPPORT WORKER/HSW
PROVIDER NO. PLAN MEMBER ID
NURSING REGISTRY INITIALPATIENT NAME
PROVINCE CITYADDRESSADDRESS
TELEPHONE NO. POSTAL CODE POSTAL CODE PROVINCE CITY
DO YOU HAVE ANY OTHER GROUP INSURANCE COVERAGE THAT MAY INCLUDE THESE SERVICES AS BENEFITS? YES NO
IF YES, INSURANCE COMPANY NAME
IF OTHER COVERAGE IS RBC LIFE, INDICATE PLAN MEMBER ID:
IS TREATMENT REQUIRED DUE TO A MOTOR VEHICLE ACCIDENT? YES NO DATE OF ACCIDENT:
IS TREATMENT REQUIRED DUE TO A WORK RELATED INJURY? YES NO
IS TREATMENT RELATED TO AN OPEN WORKER'S COMPENSATION CLAIM? YES NO DATE OF INJURY:
SERVICES WERE PROVIDED BY: RN RPN/LPN PSW/HSW NURSING FOOTCARE IN HOME IN CLINIC
DURING THE WEEK COMMENCING SUNDAY
, TO SATURDAY , ACCORDING TO THE FOLLOWING SCHEDULE:
REGISTRATION
NUMBER (IF
APPLICABLE)
NAME OF INDIVIDUAL
PROVIDING CARE
TOTAL
CHARGE
PER SHIFT
NUMBER
OF HOURS
HOURLY
RATE
HOURS WORKED
(INDICATE A.M. OR P.M.)
DATE
P.M. A.M.P.M. A.M.
To SUNDAY
To MONDAY
To TUESDAY
To WEDNESDAY
To THURSDAY
To FRIDAY
To SATURDAY
To
SUNDAY
To MONDAY
To TUESDAY
To WEDNESDAY
To THURSDAY
To FRIDAY
To SATURDAY
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 benef ts which may include the exchange of
information with other parties to administer this benef t claim.
I further authorize RBC Life to obtain and exchange information with other parties, such as health practitioners or insurers, in order to conf rm 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.
I CERTIFY THAT THE ABOVE TREATMENT WAS
RENDERED. PLEASE DIRECT PAYMENT TO THE
PROVIDER INDICATED ABOVE.
THE CHARGES LISTED ON THIS CLAIM HAVE BEEN
PAID IN FULL. PLEASE REIMBURSE THE PLAN
MEMBER DIRECTLY.
I CERTIFY THAT THE TREATMENT OUTLINED WAS
PERFORMED IN THE PATIENT'S HOME AND ALL
INFORMATION PROVIDED ON THIS FORM IS
ACCURATE
SIGNATURE OF NURSING REGISTRY OFFICIAL SIGNATURE OF PATIENT/GUARDIAN
SIGNATURE OF NURSING REGISTRY OFFICIAL
THE COST, IF ANY, OF OBTAINING THIS INFORMATION IS AT THE EXPENSE OF THE PATIENT/PLAN MEMBER.
ALL CLAIMS MUST BE RECEIVED WITHIN 12 MONTHS OF THE DATE OF SERVICE (unless otherwise stated in your benefit plan documentation).
PLEASE MAIL TO:RBC Life Insurance Company
P.O. BOX 1601 WINDSOR, ONTARIO N9A 0B4
ATTENTION: EHS DEPARTMENT
CUSTOMER SERVICE CENTRE 1-855-264-2174
Claim Form for in Home Support Services of an RN etc - EN (Rev. 2015-09) RNCLM
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