Fillable Cancer Form Attending Physicians Statement of Disability (RBC Insurance)

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Cancer Form Attending Physicians Statement of Disability (RBC Insurance)

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83160 (06/2020)
Page 1 of 3
_______________________________________ _______________________________ _____________________________
Cancer Form
Attending Physician’s
Statement of Disability
WHAT WE REQUEST AND WHY
Your patient is applying for disability benefits under a policy of disability insurance underwritten by RBC Life Insurance Company.
As you can appreciate, the information provided by you is important to our adjudication of your patient’s claim. We are asking for your
cooperation in providing pertinent information regarding the diagnosis, signs and symptoms, as well as details of your patient’s limitations
and restrictions.
We ask that you complete the Attending Physician’s Statement as thoroughly as possible. Please be assured that the information, including
the medical records requested, is required for the adjudication of your patient’s claim and will be treated confidentially.
RBC Life Insurance Company is requesting copies of your complete file for the period of treatment for this condition, including
specialist consultations, office notes, test results, hospital admission histories, discharge summaries and medical reports prepared
for other insurers on your patient and is prepared to reimburse $50.00 for the costs associated with preparing the information. If this
amount is unreasonable because of the extent of your patient’s file, please have your staff contact our office at 416-643-4700 or toll free at
1 877-519-9501. Any charge for the completion of this form, however, is the responsibility of the patient.
We would like to thank you in advance for your cooperation.
Part 1: PATIENT INFORMATION
Name: Last First Middle
_____________________________________________________________________ Telephone No: ( ) ____________________
Address (Street / City / Province / Postal Code)
Policy No(s):
Date of Birth (DD/MM/YYYY)
Claim No(s):
Part 2: DIAGNOSIS OF PRESENT CONDITION
Please attach copies of all consultation, operative and pathology reports.
Date of cancer diagnosis: (DD/MM/YYYY)
Site of tumor/Metastases:
Type of tumor:
Grade and Staging:
Current Height: ________________ Current Weight: _______________ Weight loss/gain to date: __________________
In your opinion when did the patient’s condition first prevent him/her from working? ____________________ (DD/MM/YYYY)
83160 (06/2020)
Page 2 of 3
________________________________________________________________________________________________________
_______________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Yes
Yes
Part 3: HISTORY AND FINDINGS
Date symptoms first appeared: (DD/MM/YYYY)
Has patient ever had the same or similar condition? Yes
No
If “Yes”, please specify diagnosis and dates of treatment: _______________________________________________________
Describe current symptoms: ________________________________________________________________________________
First visit for these symptoms: ______________________________________________ (DD/MM/YYYY)
Is the cancer a result of workplace exposure at the patient’s place of employment? No
If “Yes”, has your office provided documentation in support of a claim for this condition with the WSIB, Workers’
Compensation Board/CSST on behalf of your patient? Yes No
Please provide the names of other physicians who have been/will be involved in assessing the medical problems, and copies
of any available consultation reports:
Part 4: TREATMENT
Date of most recent treatment: (DD/MM/YYYY)
Frequency of visits: Weekly
Monthly Other  If “Other”, please specify: _____________________
Your patient was hospitalized as an in-patient: No
If “Yes”, hospitalized at ______________________________________ from __________________ to __________________
Out-patient treatment: Yes No
If “Yes”, treated at __________________________________________ from __________________ to __________________
Include information on all treatments to date and future treatment plan, including any surgical procedures:
Type of Treatment Start Date (DD/MM/YYYY) Length of Treatment
Radiation
Chemotherapy
Medication/Hormones
Other
Describe response to therapies to date: No Response
Partial Response Complete Response
Describe all other conditions: _______________________________________________________________________________
Describe any complications that may prolong recovery (side effects secondary to treatment/other): _____________________
What is your prognosis?
Recovery without impairment (loss of function) Number of weeks______________
Stabilization with continuing impairment Number of weeks______________
Stabilization of unknown duration
Permanent impairment
Comments: ______________________________________________________________________________________________
83160 (06/2020)
Page 3 of 3
________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________ _____________________________________________
_______________________________________________________ _____________________________________________
_______________________________________________________
X
Part 5: FUNCTIONAL ABILITIES
Please indicate your patient’s current physical abilities:
Sedentary Duties: Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly
to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary Duties involve sitting most of the time, but may
involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other
sedentary criteria are met.
Light Duties: Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5kg) of force frequently, and/or a
negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Duties. Light
Duties usually require walking or standing to a significant degree. However, if the use of the arm and/or leg controls require exertion of
forces greater than that for Sedentary Duties and the worker sits most of the time, the job is rated Light Duties.
Medium Duties: Exerting up to 50 pounds (22.7 kg) of force occasionally and/or up to 25 pounds (11.3kg) of force frequently, and/or
up to 10 pounds (4.5 kg) of force constantly to move objects.
Heavy Duties: Exerting up to 100 pounds (45.4 kg) of force occasionally and/or up to 50 pounds (22.7 kg) of force frequently, and/or
up to 20 pounds (9.1 kg) of force constantly to move objects.
Very Heavy Duties: Exerting in excess of 100 pounds (45.4 kg) of force occasionally and/or up to 50 pounds (22.7 kg) of force
frequently, and/or up to 20 pounds (9.1 kg) of force constantly to move objects.
What are the obstacles that are preventing a return to employment, if any? _________________________________________
In your opinion, what is the earliest date your patient will be able to return to work? _______________ (DD/MM/YYYY)
If the previous job could be modified, when could rehabilitative employment commence? _______________ (DD/MM/YYYY)
Driver’s license revoked: Yes No If “Yes”, please provide date: _______________ (DD/MM/YYYY)
Part 6: COMPETENCY
Do you believe your patient is competent to endorse cheques and direct the use of the proceeds thereof? Yes No
If “No”, from what date? ________________________ (DD/MM/YYYY)
If “No”, have you referred the case to the Public Trustee, or has a Guardian been appointed, or is there a Power of Attorney?
Yes No
Part 7: COMMENTS
We would appreciate any additional comments that would help us to better understand your patient and his or her condition.
SIGNATURE
Signature Date (DD/MM/YYYY)
Physician’s Name (Please print) Degree and Specialty
Primary Care Consultant
Address (Street / City / Province / Postal Code)
Email Address:
Telephone No: ( ) ____________________________________ Fax No: ( ) ________________________________
Send the completed form and documents to our ofce by email: intake@rbc.com
You can also fax the information to: RBC Life Insurance Company, Life and Health Claims Department, 1-800-714-8861.
If you have any questions, call toll free 1-877-519-9501 or 416-643-4700.
RBC Life Insurance Company, Life and Health Claims Department, P.O. Box 4435, Station A, Toronto ON, M5W 5Y8
www.rbcinsurance.com
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence. VPS107150
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Cancer Form Attending Physicians Statement of Disability (RBC Insurance)

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Completed 21 May 2021

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