Fillable Critical Illness Claim Deafness (RBC Insurance)

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Critical Illness Claim Deafness (RBC Insurance)

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Critical Illness Claim
Deafness
Condential Physician’s
Statement
Page 1 of 2
PATIENT’S INFORMATION
Name:
Last First Middle
Date of Birth:
(DD/MM/YYYY)
Policy No(s):
Claim No(s):
What We Request and Why
Your patient is applying for benets under a policy issued by RBC Life Insurance Company, and its participating reinsurers, and we will be assessing eligibility for
benets based on your patient’s medical condition. As you can appreciate, the information provided by you is most important in our assessment. We are asking for your
co-operation in providing pertinent information.
We ask that you complete the Physician’s Statement as thoroughly as possible. Please be assured that the information, including the medical records requested, is
required in the adjudication of your patient’s claim and will be treated condentially.
We are requesting copies of your complete le including specialist consultations on your patient and We are 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 le, please have your staff contact our ofce at
416-643-4700 or toll free 1-877-519-9501. Any charge for the completion of the form, however, is the responsibility of the patient.
We would like to thank you in advance for your co-operation.
DIAGNOSIS
1.
a) When did your patient rst consult you for hearing or related problems? (DD/MM/YYYY)
b)
How long has this person been your patient?
2.
On what date did your patient rst suffer symptoms or become aware of hearing loss? Please provide date and full details:
3.
a) What is the auditory threshold in each ear?
b) Please give the date of the rst audiogram that established this: (DD/MM/YYYY)
c) Please provide a copy of the audiogram, if available.
d) Please provide the name and address of the otolaryngologist:
4.
a) What is the cause of the hearing loss?
b) Is the hearing loss permanent?
c) Is there any treatment that could improve the hearing?
(over)
VPS 107187
83724 (05/2020)
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.
83724 (05/2020)
Page 2 of 2
VPS 107187
Consultant
5. Please provide the names and addresses of other physicians consulted or hospitals attended by your patient for this hearing loss or any related disorder:
Physician/Hospital Address and Telephone Dates seen
(DD/MM/YYYY)
6. Please describe any predisposing disorders or risk factors your patient had for hearing loss, and provide dates:
7.
a) Is there a family history of hearing disorders? Please provide details:
b) Please provide details of any other signicant family history:
8. 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:
9. 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? Yes
o
No
o
SIGNATURE
Signature
Physician’s Name
Address
Email Address
Telephone No.
Date (DD/MM/YYYY)
(Street / City / Province / Postal Code)
Fax No.
Degree and Specialty
Primary Care
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Critical Illness Claim Deafness (RBC Insurance)

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Completed 21 May 2021

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