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CLAIM FORM FOR RELATED HEALTH
PROFESSIONAL SERVICES
PROFESSIONAL TYPE CODES * May not be applicable to all plan members of RBC Life
1 PODIATRIST 6 CLINICAL PSYCHOLOGIST * 10 OSTEOPATH 15 HOMEOPATH
2 CHIROPODIST 7 N ATU ROPAT H 11 DIETICIAN * 16 CHRISTIAN SCIENCE PRACTITIONER
3 CHIROPRACTOR 8 SPEECH THERAPIST/PATHOLOGIST * 12 CERTIFIED ATHLETIC THERAPIST * 17 MUSCLE PHYSIOLOGIST *
4 PHYSIOTHERAPIST * 9 ACUPUNCTURE 13 SHIATSU THERAPIST 18 COUNSELLOR
5 REGISTERED MASSAGE THERAPIST * 14 OCCUPATIONAL THERAPIST 19 OTHER - Specify
* PHYSICIAN'S AUTHORIZATION MAY BE REQUIRED ON INITIAL CLAIM FOR PROFESSIONAL TYPE CODES 4, 5, 8, 11, 12, 13, 17
PLEASE NOTE: This claim form cannot be used for supplies of any type, only services or treatments. Please use one form per practitioner, as well as per patient.
PATIENT PROVIDER
COMPANY NAME DEP #PLAN MEMBER IDPROVIDER PHONE NO.
( )
PROVIDER NO.
PROFESSION TYPE CODE - Please
specify (refer to above)
NAME OF PRACTITIONER BIRTH DATE FIRST NAMESURNAME
//
DAY MOYY
ADDRESS
ADDRESS
POSTAL CODE PROV. CITY
POSTAL CODE PROV. CITY
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.
Claim only for those services rendered after provincial plan maximum has been exhausted (if applicable)
Date of last visit covered by provincial plan
/ /
YY MO DAY
DO YOU HAVE ANY OTHER GROUP INSURANCE COVERAGE THAT MAY INCLUDE
THESE SERVICES AS BENEFITS?
YES NO
CHARGES $
TAX INC.
Y or N
DAY MOYY
IF YES, INSURANCE COMPANY NAME
1.
IF OTHER COVERAGE IS RBC LIFE, INDICATE PLAN MEMBER ID b
2.
IS TREATMENT REQUIRED DUE TO A MOTOR VEHICLE ACCIDENT? blank
YES NO
3.
IF YES, DATE OF ACCIDENT
4.
IS TREATMENT REQUIRED DUE TO A WORK RELATED INJURY? bla
YES NO
5.
IF YES, DATE OF INJURY
6.
IF YES, WSIB / WCB CASE #
I CERTIFY THAT THE TREATMENT DESCRIBED ABOVE WAS PERFORMED
BY ME AND ALL INFORMATION PROVIDED ON THIS FORM IS ACCURATE.
7.
8.
9.
REGISTRATION NO., CREDENTIALS &
ASSOCIATION
SIGNATURE OF PROVIDER
I CERTIFY THAT THE ABOVE TREATMENTS WERE RENDERED.
10.
11.
PATIENT SIGNATURE
12.
I CERTIFY THAT THE ABOVE
TREATMENT WAS RENDERED AND
HEREBY AUTHORIZE PAYMENT
DIRECTLY TO THE PROVIDER
NAMED ABOVE.
THE CHARGES LISTED ON THIS
CLAIM HAVE BEEN PAID IN FULL BY
THE PLAN MEMBER. PLEASE
REIMBURSE PLAN MEMBER
DIRECTLY.
13.
14.
SIGNATURE OF PATIENT SIGNATURE OF PROVIDER
TREATMENT RENDERED
# OF HOURS - if applicable)
TOTAL
THERE IS NO NEED TO ATTACH INVOICES OR RECEIPTS IF THIS FORM
IS FULLY COMPLETED BY THE SERVICE PROVIDER
Patient Diagnosis
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 Life Insurance Company
P.O. BOX 1613, WINDSOR, ONTARIO N9A 0B8
ATTENTION: EHS DEPARTMENT
CUSTOMER SERVICE CENTRE 1-855-264-2174
CLAIM FORM FOR RELATED HEALTH
PROFESSIONAL SRV (Rev 2018-12) PROF
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