P. O. BOX 1603
Windsor, Ontario N9A 0B6
Attn: EHS Department
Customer Service Centre 1-855-264-2174
HOSPITALIZATION CLAIM FORM
HOSPITAL INFORMATION
Patient's Hospital File No.: Hospital Provider No.:
Hospital Name:
Hospital Address:
OtherConvalescent/Rehab ChronicGeneralHospital Type:
PATIENT INFORMATION
Plan Member ID
Date of Birth: / /Patient Name:
Plan Member's Name:
Patient's Relationship to Plan Member:
NoYes Does the Patient have any other semi-private/private room coverage?
If yes, please complete: Policy No.
Name of Insurer or plan
If other coverage is RBC Life, indicate Plan Member ID
NoYes Was Hospitalization required due to a motor vehicle accident?
BILLING INFORMATION
Total Amount
Claimed
Room Type
A - Active/Acute
R - Rehab
CH - Chronic/Continuing
ALC - Alternate Level Care
Discharge Date Admission DateDaily RateNo. of Days
Semi-Private Room
(Maximum 2 Beds)
* Private Room
(Maximum 1 Bed)
* If patient had private room, please enter semi-private daily rate $
AUTHORIZED HOSPITAL SIGNATURE DATE
ASSIGNMENT
I CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE. THE ROOM TYPE BEING BILLED WAS REQUESTED BY THE PATIENT. I
HEREBY ASSIGN TO THE ABOVE HOSPITAL ALL OF THE HOSPITALIZATION BENEFITS PROVIDED BY MY SAID HOSPITAL INSURANCE
OR SO MUCH THEREOF AS MAY SERVE TO SATISFY MY INDEBTEDNESS OR THAT OF MY DEPENDENT TO THE SAID HOSPITAL THIS
PERIOD OF HOSPITALIZATION.
PLAN MEMBER/EMPLOYEE
DATE
AUTHORIZATION
I HEREBY AUTHORIZE ABOVE NAMED HOSPITAL TO RELEASE THE INFORMATION REQUESTED ON THIS FORM
PATIENT OR PARENT, IF MINOR DATE
I am authorized by my spouse and/or dependents to disclose and receive information about them that is used for these purposes. I understand that this information may
be seen by the cardholder.
By signing this claim form and/or submitting actual receipts, I agree that the information provided is complete and accurate. I understand that the information provided
by me to RBC Life about myself and my dependents, will be used by RBC Life for claims adjudication and any other services necessary in the administration of our
benefits which may include the exchange of information with other parties to administer this benefit claim.
I further authorize RBC Life to obtain and exchange information with other parties, such as health practitioners or insurers, in order to confirm the accuracy of the
submitted claim(s) information. In the event of suspected fraudulent activity pertaining to claims submitted on behalf of myself and/or my dependents, I acknowledge
and agree to the disclosure of this information to relevant parties, such as the Plan Sponsor, regulatory and law enforcement agencies.
THE COST, IF ANY, OF OBTAINING THIS INFORMATION IS AT THE EXPENSE OF THE PATIENT/PLAN MEMBER.
ALL CLAIMS MUST BE SUBMITTED WITHIN 12 MONTHS OF THE DATE OF SERVICE (unless otherwise stated in your benefit plan documentation).
RBC - Hospitalization Claim Form EN (Rev. 2015-02) HOSP
click to sign
signature
click to edit
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