Page 1 of 2
Critical Illness Claim
Multiple Sclerosis
Condential 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 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.
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 briey describe the patient’s neurological signs and symptoms, giving dates and durations:
3.
On what date was the diagnosis of Multiple Sclerosis rst discussed with the patient and by whom?
4.
Please provide:
a) A copy of the imaging report conrming the diagnosis.
b) Name and address of the neurologist who conrmed the diagnosis:
(over)
