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

Fill Online, Printable, Fillable, Blank Rheumatology Form Attending Physicians Statement of Disability (RBC Insurance) Form

Use Fill to complete blank online RBC INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Rheumatology Form Attending Physicians Statement of Disability (RBC Insurance)

On average this form takes 44 minutes to complete

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

  • 1 signature
  • 0 check-boxes
  • 172 other fields

Country of origin: CANADA
File type: PDF

Use our library of forms to quickly fill and sign your RBC Insurance forms online.

BROWSE RBC INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
83156 (06/2020)
Page 1 of 4
Telephone No:
Rheumatology 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 First
Address (Street / City / Province / Postal Code)
Policy No(s):
Date of Birth (DD/MM/YYYY)
Claim No(s):
Middle
( )
Please attach copies of all consultation, operative and
pathology reports.
Part 2: DIAGNOSIS OF PRESENT CONDITION
Primary: Rheumatoid Arthritis Osteoarthritis Other Rheumatic disease
Please specify other:
Additional conditions / complications:
Reported symptoms:
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)
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:
Test Date (DD/MM/YYYY) Result
ANA
Rheumatoid factor titre
ESR
Positive synovial uids
Histological change from biopsy
Other
Yes
from
from
Yes
Part 3: HISTORY AND FINDINGS
Date of rst visit for treatment or consultation: (DD/MM/YYYY)
Date symptoms rst appeared:
(DD/MM/YYYY)
Physical ndings Please specify where
Synovitis
Yes
No
Ankylosis
Yes
No
Impaired range of motion present
Yes
No
Contracture
Yes
No
Joint Deformity
Yes
No
X-ray ndings compatible with Rheumatoid Arthritis ?
Yes
No
X-ray ndings compatible with degenerative joint disease?
Yes
No
List joints involved:
Has patient ever had the same or similar condition?
No
If “Yes”, please specify diagnosis and dates of treatment:
First visit for these symptoms: (DD/MM/YYYY)
Date of Most Recent Visit: (DD/MM/YYYY)
Is the condition due to injury or sickness arising out of the patient’s employment?
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
Part 4: TREATMENT
Date of most recent visit:
Frequency of visits: Weekly Monthly Other  If “Other”, please specify:
(DD/MM/YYYY)
Your patient was hospitalized as an in-patient:
If “Yes”, hospitalized at
Yes No
to
Out-patient treatment: Yes No
If “Yes”, treated at
Include information on all treatments to date and future treatment plan:
to
83156 (06/2020)
Page 2 of 4
Page 3 of 4
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.
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.
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.
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.
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):
Surgeries:
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:
Part 5: FUNCTIONAL ABILITIES
Please indicate your patient’s current physical abilities:
V ery 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.
83156 (06/2020)
Page 4 of 4
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence. VPS107150
X
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
83156 (06/2020)
Reset
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Rheumatology Form Attending Physicians Statement of Disability (RBC Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document