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

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Cardiac Form Attending Physicians Statement of Disability (RBC Insurance)

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  • 12 check-boxes
  • 177 other fields

Country of origin: CANADA
File type: PDF

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83158 (06/2020)
_______________________________________ _______________________________ _____________________________
Cardiac Form
Attending Physician’s
Statement of Disability
WHAT WE RE QUEST 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.
Primary: _________________________________________________________________________________________________
Additional conditions / complications: _______________________________________________________________________
Reported symptoms: ______________________________________________________________________________________
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)
Page 1 of 4
83158 (06/2020)
________________________________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Yes
Yes
Part 3: HISTORY AND FINDINGS
Yes No
Date symptoms first appeared: (DD/MM/YYYY)
Has patient ever had the same or similar condition?
If “Yes”, please specify diagnosis and dates of treatment: _______________________________________________________
First visit for these symptoms: ______________________________________________ (DD/MM/YYYY)
Describe current symptoms:
Chest pain of cardiac origin Syncope Fatigue
Dyspnea due to cardiac origin Oedema Arrhythmia
Other (please specify): _________________________________________________________________
Current blood pressure reading: ___ / ___ (Date: ___DD___MM_____YYYY)
Current status? Stable Improving Deteriorating
LABORATORY TEST (Include copies of relevant test results):
TYPE OF TEST
EKG
Echocardiogram
Stress Test
PFT
Blood Test
X-Rays
Angiogram
Ejection Fraction
Other
DATE (DD/MM/YYYY) RESULT REFERENCE VALUES
Is the condition due to injury or sickness arising out of the patient’s employment? Yes
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 visit: (DD/MM/YYYY)
Frequency of visits: Weekly
Monthly Other
Your patient was hospitalized as an in-patient: No
If “Yes”, hospitalized at ______________________________________
Out-patient treatment: No
If “Yes”, treated at __________________________________________
If “Other”, please specify: _____________________
from __________________ to __________________
from __________________ to __________________
Treatment: Include information on all treatments to date and future treatment plan, including any surgical procedures: ____
Describe response to treatment to date: No Response Partial Response Complete Response
Is patient following recommended treatment program? Yes No If “No”, please explain: _____________________
Page 2 of 4
83158 (06/2020)
Significant emotional or behavioral disorder such as depression, anxiety, etc.
Work related issues (please describe, if known):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
MEDICATIONS:
Name of
M
edication
Date Started
(DD/MM/YYYY)
Initial
Dosage
Initial
Response
Side Effects
Date Dosage
Last Changed
(DD/MM/YYYY)
Date Medication
Discontinued
(DD/MM/YYYY)
Describe any complications that may prolong recovery (side effects secondary to treatment/other): _____________________
Assessment and treatment are complicated by: (Please check and explain in the space provided)
Inconsistent findings, subjective complaints out of proportion to objective findings, contradictory observations.
_____________________________________________________________
Substance abuse: ______________________________________________________________________________________
Other (please describe): _________________________________________________________________________________
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: ______________________________________________________________________________________________
Part 5: FUNCTIONAL ABILITIES
Please indicate your patient’s current physical abilities:
Functional capacity (Canadian Cardiovascular Society, CCS):
Class 1 (no limitation) Class 2 (mild impairment) Class 3 (moderate impairment) Class 4 (severe impairment)
Lifting /
Carrying
Pushing/
Pulling
Standing
Walking
Weight
1-10 lbs ( 0.5-4.5kg)
11-20 lbs ( 5.0-9.1kg)
21-50 lbs (9.5- 22.7 kg)
1-10 lbs ( 0.5-4.5kg)
11-20 lbs ( 5.0-9.1kg)
21-50 lbs (9.5- 22.7 kg)
Hours
Blocks
Frequency Duration
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)
Page 3 of 4
83158 (06/2020)
________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_______________________________________________________ _____________________________________________
_______________________________________________________
REHABILITA
TION:
a) Is the patient in a cardiac rehabilitation program? Yes No
b) Is patient a suitable candidate for vocational rehabilitation? Yes No
c) If “Yes”, please specify: _________________________________________________________________________________
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
X
_______________________________________________________ _____________________________________________
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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Cardiac Form Attending Physicians Statement of Disability (RBC Insurance)

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Completed 21 May 2021

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