83754 (05/2020)
Page 1 of 2
VPS 107187
Critical Illness Claim
Occupational HIV Infection
Condential Physician’s
Last First Middle
Date of Birth:
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.
a) Please advise on what date your patient rst had symptoms of the condition, and advise what those symptoms were:
b) When did your patient rst consult you for this condition? (DD/MM/YYYY)
c) How long has this person been your patient?
Please provide the date the Occupational HIV Infection was diagnosed and the dates investigated:
b) On what date was the patient advised of the diagnosis (DD/MM/YYYY) and by whom?
Please provide copies of all test results and investigations.
What is the most recent CD4 Count (AKA Tcell Count): (approx 0-800)
b) Provide copies of Viral Load Counts:
c) When were these last measured?
83754 (05/2020)
Page 2 of 2
VPS 107187
Primary Care
5. Please provide the names and addresses of other physicians consulted or hospitals attended by your patient for this Occupational HIV Infection:
Physician/Hospital Address and Telephone Dates seen
6. a) What are the medications currently?
b) Have any been changed recently?
c) How are the medications working?
d) Please list any side effects:
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:
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?
Signature Date (DD/MM/YYYY) Degree and Specialty
Physician’s Name Consultant
(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
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
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