Fillable Critical Illness Claim Major Organ Transplant / Major (RBC Insurance)

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Critical Illness Claim Major Organ Transplant / Major (RBC Insurance)

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83700 (05/2020)
Page 1 of 2 VPS 107187
Please give details of the transplant procedure performed, including the name and address of the hospital, the attending surgeon/physician and the date
of the procedure:
PATIENT’S INFORMATION
Critical Illness Claim
Major Organ Transplant / Major
Organ Failure Requiring Transplant
Condential Physician’s
Statement
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.
Please provide complete details of the disorder leading to your patient’s transplant procedure:
2.
a) On what date did your patient rst suffer symptoms of this disorder? (DD/MM/YYYY)
b) What were the symptoms described by the patient?
c) On what date was the disorder rst diagnosed? (DD/MM/YYYY)
d) On what date was the patient made aware of the diagnosis and by whom?
e) How long has this person been your patient?
3.
How long had end stage disease been present?
4.
(over)
Page 2 of 2
Yes
Date (DD/MM/YYYY)
Primary Care
Consultant
5. Please describe any predisposing disorders or risk factors that your patient had for the underlying disorder, and provide dates:
6. Please provide the names and addresses of other physicians consulted or hospitals attended by your patient for this or any related condition:
Physician/Hospital Address and Telephone Dates seen
(DD/MM/YYYY)
7. a) Is there anything in your patient’s habits or family history that increased the risk for the underlying disorder? Yes
o
No
o
If “Yes,” please provide details:
b) Please provide details of any 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?
o
No
o
SIGNATURE
Signature Degree and Specialty
Physician’s Name
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.
83700 (05/2020)
VPS 107187
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Critical Illness Claim Major Organ Transplant Major (RBC Insurance)

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Completed 21 May 2021

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