Fillable Critical Illness Claim Motor Neuron Disease (RBC Insurance)

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Critical Illness Claim Motor Neuron Disease (RBC Insurance)

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83704 (05/2020)
Page 1 of 2
VPS 107187
Critical Illness Claim
Motor Neuron Disease
Condential Physician’s
Statement
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) Please indicate the date when your patient rst had symptoms: (DD/MM/YYYY)
b) On that date, what were the symptoms?
c) How long has this person been your patient?
2.
Please outline the clinical course and briey describe the patient’s neurological signs and symptoms, giving dates and durations:
3.
On what date was the diagnosis of Motor Neuron Disease rst discussed with the patient and by whom?
(DD/MM/YYYY)
4.
Please provide:
a) A copy of the imaging report conrming the diagnosis.
b) Name and address of the neurologist who conrmed the diagnosis:
c) Copies of all test results.
(over)
83704 (05/2020)
Page 2 of 2
VPS 107187
5. 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)
6. a) Is there a family history of Motor Neuron Disease? Please provide details:
b) Please provide details of any other signicant family history:
7. 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:
8. 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 Consultant
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 Motor Neuron Disease (RBC Insurance)

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Completed 21 May 2021

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