CLAIM FORM FOR MEDICAL DEVICES
PLEASE USE ONE FORM PER PRACTITIONER, PER PATIENT. PLEASE DO NOT USE THIS FORM FOR: CUSTOM-MADE FOOT ORTHOTICS OR
CUSTOM FOOTWEAR
Additional supplies of this form are available at www.rbcinsurance.com/business/group-insurance/index.html.
PATIENT PROVIDER
COMPANY NAME DEP #PLAN MEMBER IDPROVIDER PHONE NO.
( )
PROVIDER NO.
PROVIDER NAME BIRTH DATE FIRST NAMESURNAME
//
DDMMYY
ADDRESS ADDRESS
POSTAL CODE PROVINCE CITYPOSTAL CODE PROVINCE CITY
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.
MEDICAL DEVICES PROVIDED
1.
2.
3.
YY MM DD TAX INC. CHARGES $
4.
5.
TOTAL
A physician's prescription or authorization may be required to complete the processing of this claim.
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
DATE OF ACCIDENT
IS TREATMENT REQUIRED DUE TO A MOTOR VEHICLE ACCIDENT? YES NO
IS TREATMENT REQUIRED DUE TO A WORK RELATED INJURY? YES NO
DATE OF INJURY
IS TREATMENT RELATED TO AN OPEN WORKER'S COMPENSATION CLAIM? YES NO
I CERTIFY THAT THE TREATMENT DESCRIBED ABOVE WAS RENDERED BY ME AND ALL INFORMATION PROVIDED ON THIS FORM IS ACCURATE.
REGISTRATION NO., CREDENTIALS & ASSOCIATION SIGNATURE OF PROVIDER
I CERTIFY THAT THE ABOVE MEDICAL DEVICES WERE RECEIVED.
SIGNATURE OF PATIENT
I CERTIFY THAT THE ABOVE LISTED MEDICAL DEVICES WERE RECEIVED AND
HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE PROVIDER.
THE CHARGES LISTED ON THIS CLAIM HAVE BEEN PAID IN FULL BY THE
PLAN MEMBER. PLEASE REIMBURSE PLAN MEMBER DIRECTLY.
SIGNATURE OF PATIENT SIGNATURE OF PROVIDER
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).
PLEASE ATTACH ALL ORIGINAL PAID RECEIPTS, PRESCRIPTIONS AND AUTHORIZATION FORMS.
Please retain copies for your files as original receipts will not be returned.
RBC Life Insurance Company
P.O. BOX 1613, Windsor, ONTARIO N9A 0B8
ATTENTION: EHS DEPARTMENT
CUSTOMER SERVICE CENTRE 1-855-264-2174
MEDEV
RBC-Claim Form for Medical Device EN(Rev. 2018-12)
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