Fillable Critical Illness Claim Parkinsons Disease (RBC Insurance)

Fill Online, Printable, Fillable, Blank Critical Illness Claim Parkinsons Disease (RBC Insurance) Form

Use Fill to complete blank online RBC INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Critical Illness Claim Parkinsons Disease (RBC Insurance)

On average this form takes 14 minutes to complete

The Critical Illness Claim Parkinsons Disease (RBC Insurance) form is 2 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 51 other fields

Country of origin: CANADA
File type: PDF

Use our library of forms to quickly fill and sign your RBC Insurance forms online.

BROWSE RBC INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
83702 (05/2020)
Page 1 of 2
VPS 107187
Critical Illness Claim
Parkinson’s Disease
Has your patient suffered any previous episode(s) of this condition, or any conditions leading to or related to it?
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.
On what date were you rst consulted for symptoms resulting in your diagnosis of Parkinson’s Disease and, at that time, how long had impairment been
present?
2.
a) When was your patient rst given a rm diagnosis of Idiopathic Parkinson’s Disease and by whom?
b) How long has this person been your patient?
3.
Please provide details:
4.
Please provide details of the diagnosis:
5.
Please provide details, including dates, of the extent of the neurological decit. Have these abnormalities been present continuously?
6.
a) Did Parkinson’s Disease result from treatment for any other illness, or is it associated with any other disease (ie. Atherosclerosis, Supranuclear
Palsy)?
Yes
o
No
o If “Yes,” please provide details:
(over)
83702 (05/2020)
Page 2 of 2
VPS 107187
Did features of Parkinson’s Disease occur as a side effect of any prescribed drug therapy or illicit drug use?
Yes
b)
Yes
o
No
o
If “Yes,” please provide details:
7. Please provide details of any investigations performed:
8. Please provide details of current treatment:
9. 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)
10. a) Is there a family history of Parkinson’s Disease? Please provide details:
b) Please provide details of any other 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?
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.
Reset
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Critical Illness Claim Parkinsons Disease (RBC Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document