Fillable Critical Illness Claim Loss of Speech (RBC Insurance)

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Critical Illness Claim Loss of Speech (RBC Insurance)

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Critical Illness Claim
Loss of Speech
Condential Physician’s
Statement
83698 (05/2020)
Page 1 of 2
VPS 107187
a)
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.
When did your patient rst consult you for loss of speech? (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 loss of speech? Please provide date and full details:
3.
a)
Please provide details of the injury or disease causing loss of speech, and provide dates:
b) Is the loss of speech permanent and irreversible?
c) Please describe the degree and type of loss of speech:
4.
Were there any associated neurological or psychological complications, including hysterical aphonia?
5.
Please indicate duration and frequency of any speech therapy sessions:
(over)
83698 (05/2020)
Page 2 of 2
VPS 107187
6.
Has there been any improvement in the patient’s speech since the onset of the condition?
7.
What investigations or tests have been performed to verify the diagnosis of permanent loss of speech?
8. Has your patient suffered any previous episodes of loss of speech or any condition leading to or related to it?
9. Please provide the names and addresses of other physicians or speech language therapists consulted, or hospitals attended by your patient for this
condition:
Physician/Hospital Address and Telephone Dates seen
(DD/MM/YYYY)
10. Please provide details of any signicant family history:
11. 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:
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? Yes
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 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.
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Critical Illness Claim Loss of Speech (RBC Insurance)

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Completed 21 May 2021

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