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

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Psychiatric Form Statement of Disability Attending Physicians (RBC Insurance)

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The Psychiatric Form Statement of Disability Attending Physicians (RBC Insurance) form is 4 pages long and contains:

  • 1 signature
  • 9 check-boxes
  • 184 other fields

Country of origin: CANADA
File type: PDF

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WHAT WE REQUEST AND WHY
Y
W
83164 (06/2020)
Page 1 of 4
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.
e 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 photocopying.
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.
Psychiatric Form
Supporting Data: (Please describe the symptoms, severity, frequency
and any medical or psychological tests that support each axis.)
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 First
Address (Street / City / Province / Postal Code)
Policy No(s):
Date of Birth (DD/MM/YYYY)
Claim No(s):
Middle
Telephone No: ( )
Part 2: DIAGNOSIS OF PRESENT CONDITION
Please attach copies of all consultation reports.
DIAGNOSIS: (Please use DSM-IV or DSM-5)
Axis I
Axis II
Axis III
Axis IV
Please list symptoms that presently limit activity and function:
No
No
No
MENTAL STATUS EXAMINATION:
DATE (DD/MM/YYYY) NORMAL/ABNORMAL DESCRIPTION
Appearance
Behaviour
Speech
Affect
Mood
Cognition
Insight
Judgement
Other
PRECIPITATING AND COMPLICATING FACTORS (Please describe all factors that may have contributed to the onset
of the clinical problem(s) or may complicate their resolution):
Workplace Issues:
Social/Family Issues:
Alcohol/Drug Use/Gambling: Yes
No
Addictions /Substance Abuse Program: Yes
No
Eating Disorders/Attention Decit Hyperactivity Disorder: Yes
No
Physical Medical Condition:
Financial/Legal Problems:
Yes
No
Personality Style/Motivation:
Coping Skills:
Changes in Activities of Daily Living (ADL) habits:
Current Height: Current Weight: Weight Loss/Gain:
Other Issues:
(Please provide copies of all relevant clinical and consultation reports
on le):
Part 3: HISTORY AND FINDINGS
Date symptoms rst appeared Date: (DD/MM/YYYY)
When did symptoms worsen Date: (DD/MM/YYYY)
First visit for treatment or consultation Date: (DD/MM/YYYY)
Date patient’s symptoms rst prevented them from working Date: (DD/MM/YYYY)
Date of most recent visit Date: (DD/MM/YYYY)
Frequency of visits:
Has patient ever had the same or similar condition? Yes
If “Yes”, please specify diagnosis and dates of treatment:
Is the condition due to injury or sickness arising out of the patient’s employment? Yes
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
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:
Page 2 of 4
83164 (06/2020)
Partial Response
from
Part 4: TREATMENT
PSYCHOTHERAPY:
Type of therapy: Therapy goal and focus:
Frequency & Length of sessions:
Number of therapy/counseling sessions to date:
Treatment compliance:
Treatment response to date:
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)
TREATMENT SUMMARY:
Overall response to treatment:
Expected outcomes and timeframe:
Patient’s motivation and compliance:
Are there recommended treatments that your patient cannot access?
Which of the following symptoms continue? limitations in work and interest
anxiety physical symptoms
anxiety
List others:
depressed mood
low libido
guilt
suicidality
low energy
TREATMENT FOR NON-PSYCHIATRIC/PSYCHOLOGICAL ISSUES:
Treatment For What Condition? Treatment Provider or Facility (name, address, clinical specialty)
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 to
FUTURE TREATMENT PLANS:
What changes in your treatment are underway or are being considered?
Other:
Describe response to treatment to date: No Response
o
Complete Response
Describe any complications that may prolong recovery:
Page 3 of 4
83164 (06/2020)
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence. VPS107150
What is your prognosis?
o Recovery without impairment (loss of function) Number of weeks
o Stabilization with continuing impairment Number of weeks
o Stabilization of unknown duration
o Permanent impairment
Comments:
Part 5: FUNCTIONAL ABILITIES
In your opinion, what is the earliest date your patient will be able to return to work? (DD/MM/YYYY)
Driver’s license revoked: Yes o No o If “Yes”, please provide date: (DD/MM/YYYY)
(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
Physician’s Name (Please print)
Date (DD/MM/YYYY)
Degree and Specialty
Address (Street / City / Province / Postal Code)
Email Address:
o Primary Care o Consultant
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
Page 4 of 4
83164 (06/2020)
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Psychiatric Form Statement of Disability Attending Physicians (RBC Insurance)

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Completed 21 May 2021

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