CLAIM FORM FOR VISION CARE SERVICES
Please use one form per practitioner, per patient. There is no need to attach receipts if this form is completed in full by the provider.
PROVIDER INFORMATION SECTION 1 - PATIENT INFORMATION
PROVIDER PHONE # PROVIDER NUMBER COMPANY NAME PLAN MEMBER ID
DATE OF BIRTH (YY/MM/DD) SURNAME FIRST NAME PROVIDER NAME
ADDRESSADDRESS
POSTAL CODE PROVINCE CITY POSTAL CODE PROVINCE CITY
SECTION 2 - MANDATORY DECLARATION
Do you have any other group insurance coverage that may include these services as benefits? YES NO
If Yes, please provide Insurance company's name _________________________________________________ AND attach copy of statement from primary carrier.
If other coverage is RBC Life, indicate Plan Member ID: ___________________________________
Is treatment due to a motor vehicle accident? YES NO Date of Accident (YY/MM/DD) _____________________________
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 (YY/MM/DD) _____________________________
SECTION 3a - EYE EXAM CLAIM DETAILS (ONLY IF INCLUDED WITH THIS SUBMISSION)
OPTOMETRIST NAME, ADDRESS & PHONE NUMBER PROVIDER NUMBER
YEAR MONTH DAY
EYE EXAM
PAY PLAN MEMBER
PAY PROVIDER
$
AMOUNT
SECTION 3b - EYEWEAR CLAIM DETAILS
DATE EYEWEAR RECEIVED OR PAID IN FULL: __________________________________________
CHARGES
FRAMES
YEAR MONTH DAY
EYEGLASS LENSES
CONTACT LENSES
MISC./DIAGNOSTIC TEST
1. ________________
2. ________________
TOTAL
BALANCETO PROVIDER
PATIENT PAID
SPHERE CYLINDER AXIS PRISM
R
LDISPENSING FEE
BIFOCAL PROGRESSIVE
BIFOCAL
TRIFOCAL TINT
Colour & No
R R R
SECTION 4 - AUTHORIZATION
MUST BE COMPLETED IN ALL
CASES BY SUPPLIER:
New Prescription
Safety Glasses
Lenses Only
Post Cataract claim
If Post Cataract claim, does
patient have lens implant?
YES
NO
LLL
NO
NO
CONTACT LENSES:
Can visual acuity be restored to at least 20/70 in the better eye with conventional eye glasses? YES
Can visual acuity be restored to at least 20/40 in the better eye with conventional eye glasses? YES
Are they medically necessary due to keratoconus, irregular astigmatism or irregular corneal curvature? YES NO
I UNDERSTAND THAT THE CHARGES LISTED IN THIS CLAIM MAY NOT BE COVERED BY OR MAY EXCEED MY BENEFIT PLAN. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE
TO THE SUPPLIER FOR THE COST OF THOSE SERVICES.
SIGNATURE OF PATIENT OR LEGAL GUARDIAN
THE CHARGES LISTED ON THIS CLAIM HAVE BEEN PAID IN FULL BY THE PATIENT. PLEASE
REIMBURSE PATIENT DIRECTLY.
SIGNATURE OF PROVIDER
COMPLETE THIS SECTION ON THE DATE OF PICK UP. I CERTIFY THAT THE ABOVE
TREATMENT WAS RENDERED AND HEREBY ASSIGN PAYMENT DIRECTLY TO THE
PROVIDER.
SIGNATURE OF PATIENT OR LEGAL GUARDIAN
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.
SECTION 5 - MAILING INSTRUCTIONS
PLEASE ATTACH ALL ORIGINAL CORRESPONDENCE and retain copies for your files as original receipts will not be returned. 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.
CUSTOMER SERVICE CENTRE 1-855-264-2174
PLEASE INDICATE ON MAILING ENVELOPE: RBC Life Insurance Company, P.O. BOX 1603, WINDSOR, ON N9A 0B6 ATTENTION: VISION DEPARTMENT
b s
www.rbcinsurance.com/planmember
Claim Form for Vision EN (Rev. 2018-12) VIS
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