Critical Illness Claim
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Last First Middle
Date of Birth:
What We Request and Why
Your patient is applying for benets under a policy issued by RBC Life Insurance Company, and its participating reinsurers, and we will be assessing eligibility for
benets 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 condentially.
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 ofce 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.
a) When did your patient rst consult you for renal disease? (DD/MM/YYYY)
b) How long has this person been your patient?
On what date did your patient rst suffer symptoms or become aware of renal disease or impaired renal function? Please provide date and details of the
a) Does your patient have end stage irreversible failure of both kidneys?
b) What is the cause of the renal failure?
c) Is regular renal dialysis being performed?
d) On what date did your patient rst start dialysis and indicate type of dialysis:
e) Has a renal transplant taken place or is it proposed for the future?
Please provide results of relevant investigations and laboratory results: