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

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Musculoskeletal Form Attending Physicians Statement of Disability (RBC Insurance)

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Country of origin: CANADA
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83162 (06/2020)
Page 1 of 4
_______________________________________ _______________________________ _____________________________
Musculoskeletal Form
Attending Physician’s
Statement of Disability
Telephone No:
leg(s)
WHAT WE REQUEST AND WHY
Your patient is applying for disability benefits 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 confidentially.
RBC Life Insurance Company is requesting copies of your complete file for the period of treatment for this condition, including
specialist consultations, office 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 file, please have your staff contact our office 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 First Middle
_____________________________________________________________________ ( ) ____________________
Address (Street / City / Province / Postal Code)
____________________________________ Policy No(s): __________________________________________________________
Date of Birth (DD/MM/YYYY)
Claim No(s): __________________________________________________________
Part 2: DIAGNOSIS OF PRESENT CONDITION
Please attach copies of all consultation, operative and pathology reports.
Primary: ________________________________________________________________________________________________
Additional conditions / complications: _______________________________________________________________________
Reported symptoms:
1. Pain in the cervical
o thoracic o lumbosacral area o
2. Stiffness or impaired range of motion o
3. Weakness or incoordination o
4. Parasthesias or sensory disturbance in radicular or dermotomal pattern in the arm(s) o o trunk o
5. Other (please specify): _______________________________________________________________________________________
Current Height: ________________ Current Weight: _______________ Weight loss/gain to date: __________________
In your opinion when did the patient’s condition first prevent him/her from working? ____________________ (DD/MM/YYYY)
83162 (06/2020)
Page 2 of 4
____________________________________________________________________________________________________
Please outline all tests/studies that have been performed:
Test Date (DD/MM/YYYY) Result
X-ray
MRI
EMG
Nerve Conduction Sudies
Ultrasound
Other
Part 3: HISTORY AND FINDINGS
Date of first visit for treatment or consultation: ______________________________________________ (DD/MM/YYYY)
Date symptoms first appeared:
___________________________________________________________
(DD/MM/YYYY)
Please indicate the nature and severity of the patient’s symptoms and signs:
Symptoms
Please specify
location(s)
Physical Findings Severe Moderate Mild Absent
Pain
Deformity
Muscle Spasm
Muscle Atrophy
Loss of Tendon Reflexes
Sensory Change
Motor Deficit
Straight Leg Raising Limitation
Range of Motion Limitation
Swelling
Other (please specify)
If Arthritis Condition: In remission
Continuously active
Stable
Seasonally active
Intermittently active
Progressive
o
If Fracture: Closed
Open
Multifragmented
o
Has patient ever had the same or similar condition? Yes
No
If “Yes”, please specify diagnosis and dates of treatment ____________________________________________________
____________________________________________________________________________________________________
Date of Most Recent Visit: __________________________ (DD/MM/YYYY)
Is the condition due to injury or sickness arising out of the patient’s employment? Yes No
If “Yes”, has your office 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 filled 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: _____________________________________________________________
83162 (06/2020)
Page 3 of 4
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Part 4: TREATMENT
Yes
Yes
Date of most recent treatment: ___________________________________________________________ (DD/MM/YYYY)
Frequency of visits: Weekly Monthly Other 
Your patient was hospitalized as an in-patient: No
If “Yes”, hospitalized at ______________________________________
Out-patient treatment: No
If “Yes”, treated at __________________________________________
If “Other”, please specify: _____________________
from __________________ to __________________
from __________________ to __________________
Include information on all treatments to date and future treatment plan: ___________________________________________
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)
Physiotherapy (type, frequency, dates): _____________________________________________________________________
Other: _______________________________________________________________________________________________
Describe response to treatment to date: No Response 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: _____________________
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: ______________________________________________________________________________________________
83162 (06/2020)
Page 4 of 4
________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
X
Part 5: FUNCTIONAL ABILITIES
Please indicate your patient’s current physical abilities:
o 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.
o 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 significant 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.
o 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.
o 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.
o 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 modified, when could rehabilitative employment commence? _______________ (DD/MM/YYYY)
Driver’s license revoked: Yes
o No o 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 o No o
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 o No o
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
o Primary Care o 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. VPS107150
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Musculoskeletal Form Attending Physicians Statement of Disability (RBC Insurance)

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Completed 21 May 2021

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