Page 2 of 2
If “Yes,” please provide details:
Yes
6. Did Alzheimer’s Disease result from treatment for any other illness, or is it associated with any other disease (ie: CNS, systemic or substance-induced
conditions)?
Yes
o
No
o
7. Please provide details of any investigations performed:
8.
Please provide details of current treatment:
9.
a) Please provide details of your patient’s past and present tobacco use, including amount per day and date last used:
b) Please provide details of your patient’s past and present use of any smoking cessation products, including amount per day and date last used:
10. Please provide the names and addresses of other physicians consulted or hospitals attended by your patient for this condition:
Physician/Hospital Address and Telephone Dates seen
(DD/MM/YYYY)
11.
a) Is there a family history of Alzheimer’s Disease or any genetically determined CNS disease? Please provide details:
b) Please provide details of any other signicant family history:
12.
Please provide any other information that would be helpful in the assessment of your patient’s claim:
Our contract requires that a covered illness be diagnosed by a physician who is not related to or in a business relationship with the insured. Are you related to or in a
business relationship with this patient?
o
No
o
SIGNATURE
Signature Date (DD/MM/YYYY) Degree and Specialty
Physician’s Name Primary Care Consultant
Address
(Street / City / Province / Postal Code)
Email Address
Telephone No. Fax No.
Send the completed form and documents to our ofce 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.
click to sign
signature
click to edit