Fillable General Form Attending Physicians Statement of Disability (RBC Insurance)

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General Form Attending Physicians Statement of Disability (RBC Insurance)

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83172 (06/2020)
Page 1 of 4
( Telephone No: )
General Form
Attending Physician’s
Statement of Disability
WHAT WE REQUEST AND WHY
Your patient is applying for disability benets under a policy of disability insurance underwritten by RBC Life Insurance Company.
As you can appreciate, the information provided by you is important to our adjudication of your patient’s claim. We are asking for your
cooperation in providing pertinent information regarding the diagnosis, signs and symptoms, as well as details of your patient’s limitations and
restrictions.
We ask that you complete the Attending Physician’s Statement as thoroughly as possible. Please be assured that the information, including
the medical records requested, is required for the adjudication of your patient’s claim and will be treated condentially.
RBC Life Insurance Company is requesting copies of your complete le for the period of treatment for this condition, including
specialist consultations, ofce notes, test results, hospital admission histories, discharge summaries and medical reports prepared
for other insurers on your patient and is 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 at
1 877-519-9501. Any charge for the completion of this form, however, is the responsibility of the patient.
We would like to thank you in advance for your cooperation.
Part 1: PATIENT INFORMATION
Name: Last
Address (Street / City / Province / Postal Code)
Date of Birth (DD/MM/YYYY)
First
Policy No(s):
Claim No(s):
Middle
Please attach copies of all consultation, operative and
pathology reports.
Part 2: DIAGNOSIS OF PRESENT CONDITION
Primary:
Additional conditions / complications:
Reported symptoms:
If diagnosis is pregnancy, give E.D.C.: (DD/MM/YYYY)
Current Height: Current Weight: Weight loss/gain to date:
In your opinion when did the patient’s condition rst prevent him/her from working? (DD/MM/YYYY)
CARDIAC (if applicable) Please forward copies of exercise stress, angiogram, or other relevant documentation:
a) Functional capacity (Canadian Cardiovascular Society, CCS):
Class 1 (no limitation) Class 2 (mild impairment) Class 3 (moderate impairment) Class 4 (severe impairment)
b) Last three Blood Pressure Readings:
___ / ___ (Date: ___DD___MM____YYYY) ___ / ___ (Date: ___DD___MM____YYYY) ___ _/ __ (Date: ___DD___MM____YYYY)
Reading Reading Reading
Page 2 of 4
PSYCHIATRIC (if applicable) Please indicate each Axis of DSM V DIAGNOSIS, using DSM-IV or DSM-5 Criteria. Please
also describe the symptoms, severity and frequency and any medical or psychological tests that support each axis:
Axis I
Axis II
Axis III
Axis IV
Please list symptoms that presently limit activity and function:
MENTAL STATUS EXAMINATION:
DATE (DD/MM/YYYY) NORMAL/ABNORMAL DESCRIPTION
Appearance
Behaviour
Speech
Affect
Mood
Cognition
Insight
Judgement
Other
Precipitating Events:
Work Issues:
Changes in Activities of Daily Living (ADLs) habits:
Are patient’s symptoms due to drug or alcohol abuse? Yes
No
If “Yes”, is patient enrolled in a substance abuse program? Yes No
If “Yes”, state facility:
Date of admission and discharge (if applicable):
Part 3: HISTORY AND FINDINGS
Date symptoms rst appeared: (DD/MM/YYYY)
Has patient ever had the same or similar condition? Yes No
If “Yes”, please specify diagnosis and dates of treatment:
Describe current symptoms:
First visit for these symptoms: (DD/MM/YYYY)
Is the condition due to injury or sickness arising out of the patient’s employment? Yes No
If “Yes”, has your ofce provided documentation in support of a claim for this condition with the WSIB, Workers’
Compensation Board/CSST on behalf of your patient? Yes No
Have you lled out forms for an Auto Insurance carrier? Yes No
If “Yes”, please advise of name of carrier Policy number
Please provide the names of other physicians who have been/will be involved in assessing the medical problems, and copies
of any available consultation reports:
83172 (06/2020)
Page 3 of 4
No Response
Part 4: TREATMENT
Date of most recent treatment: (DD/MM/YYYY)
Frequency of visits: Weekly Monthly Other  If “Other”, please specify:
Your patient was hospitalized as an in-patient: Yes No
If “Yes”, hospitalized at from to
Out-patient treatment: Yes No
If “Yes”, treated at from to
Treatment: Include information on all treatments to date and future treatment plan, including any surgical procedures:
Other:
Describe response to treatment to date: Partial Response Complete Response
Describe any complications that may prolong recovery (side effects secondary to treatment/other):
Is patient following recommended treatment program? Yes No If “No”, please explain:
MEDICATIONS:
Name of
Medication
Date Started
(DD/MM/YYYY)
Initial
Dosage
Initial
Response
Side Effects
Date Dosage
Last Changed
(DD/MM/YYYY)
Date Medication
Discontinued
(DD/MM/YYYY)
What is your prognosis?
Recovery without impairment (loss of function) Number of weeks
Stabilization with continuing impairment Number of weeks
Stabilization of unknown duration
Permanent impairment
Comments:
83172 (06/2020)
Page 4 of 4
( (
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.VPS107150
X
Part 5: FUNCTIONAL ABILITIES
Please indicate your patient’s current physical abilities:
Sedentary Duties: Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly
to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary Duties involve sitting most of the time, but may
involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other
sedentary criteria are met.
Light Duties: Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5kg) of force frequently, and/or a
negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Duties. Light
Duties usually require walking or standing to a signicant degree. However, if the use of the arm and/or leg controls require exertion of
forces greater than that for Sedentary Duties and the worker sits most of the time, the job is rated Light Duties.
Medium Duties: Exerting up to 50 pounds (22.7 kg) of force occasionally and/or up to 25 pounds (11.3kg) of force frequently, and/or up
to 10 pounds (4.5 kg) of force constantly to move objects.
Heavy Duties: Exerting up to 100 pounds (45.4 kg) of force occasionally and/or up to 50 pounds (22.7 kg) of force frequently, and/or up
to 20 pounds (9.1 kg) of force constantly to move objects.
Very Heavy Duties: Exerting in excess of 100 pounds (45.4 kg) of force occasionally and/or up to 50 pounds (22.7 kg) of force
frequently, and/or up to 20 pounds (9.1 kg) of force constantly to move objects.
What are the obstacles that are preventing a return to employment, if any?
In your opinion, what is the earliest date your patient will be able to return to work? (DD/MM/YYYY)
If the previous job could be modied, when could rehabilitative employment commence? (DD/MM/YYYY)
Driver’s license revoked: Yes No If “Yes”, please provide date: (DD/MM/YYYY)
Part 6: COMPETENCY
Do you believe your patient is competent to endorse cheques and direct the use of the proceeds thereof? Yes No
If “No”, from what date? (DD/MM/YYYY)
If “No”, have you referred the case to the Public Trustee, or has a Guardian been appointed, or is there a Power of Attorney?
Yes No
Part 7: COMMENTS
We would appreciate any additional comments that would help us to better understand your patient and his or her
condition.
SIGNATURE
Signature Date (DD/MM/YYYY)
Physician’s Name (Please print) Degree and Specialty
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
83172 (06/2020)
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General Form Attending Physicians Statement of Disability (RBC Insurance)

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Completed 21 May 2021

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