Aflac wellness claim forms printable fill online, printable, fillable. This form is what you would use in the event of injury from an accident or it may be used if you have benefits that cover wellness procedures such as mammograms. American family life assurance company of columbus aflac. Forms received without signature will not be processed. Fill out, securely sign, print or email your aflac accident claim form instantly with signnow. Your aflac policy provides one wellness benefit per covered person, per calendar year, and this form is. Please submit the pathology report used in the diagnosis of a malignant cancer, the claimants birth certificate, and any itemized medical bills with the diagnosis and procedure codes, as well as a signed and dated authorization for disclosure of health information hipaa form. Keep a copy of the supporting documentation and this completed form for your records. Accident wellness benefit claim form failure to complete all sections may result in a delay in processing this claim. Accident wellness benefit claim form snohomish county.
Your aflac new york policy provides one wellness benefit per covered person, per calendar year, and this. Accident wellness benefit claim form instructions please use black or blue ink only and print legibly when completing this form in its entirety. You may either write a lengthy letter to make your claim, or you may fill the easy. Sign, fax and printable from pc, ipad, tablet or mobile with pdffiller. We care about aflacs policyholders affected by the recent severe weather. Continental american insurance company caic, a proud member of the aflac family of insurers, is a whollyowned subsidiary of aflac incorporated and underwrites group coverage. Failure to complete all sections may result in a delay in processing this claim. Cancer screening wellness benefit claim form please use black or blue ink only and print legibly when completing this form in its entirety. Claims department, worldwide headquarters, 1932 wynnton road, columbus, ga 31999, as soon as. Please use black or blue ink only and print legibly when completing this form in its entirety. Mark only wellness exam boxes for tests that you had. Critical illness health screening form failure to complete all sections may result in a delay in processing this claim. Physical therapy must be for injuries sustained in a covered accident and must start within 30 days of the covered accident or discharge from the.
Fill aflac wellness claim forms printable, edit online. Fill out, securely sign, print or email your hospital indemnity wellness benefit claim form aflac group insurance instantly with signnow. And since we can process your claim quickly, aflac helps give you the peace of mind knowing you can spend more time recovering and less time worrying about bills. Some of the tests listed may not be covered under the wellness benefit of your policy. Aflac accident hospital indemnity wellness benefit claim. Download aflac cancer screening wellness benefit claim form. I am able to modify the forms to fit my special needs and requirements. Aflac printable claim forms esign pdf with electronic. Accident wellness benefit claim form some of the tests listed may not be covered under the wellness benefit of your policy. Please sign the attached hipaa form and return it with the completed claim form.
To prevent delays, please provide documentation from your healthcare provider to support this claim. Download aflac accident wellness benefit claim form pdf. Start a free trial now to save yourself time and money. Aflacs wellness benefit claim form is available online by visiting, clicking on enter under the individuals and policyholders heading, and then clicking on claim forms. The facts say you need the protection of the aflac accident advantage insurance policy. Accident wellness benefit claim form do not write on form except as instructed. Pdf accidenthospital indemnity wellness benefit claim.
Failure to complete this form in its entirety may result in a delay in processing this claim. Fax this form to 18774423522 or return the form to aflac, attn. Wellness claim form if you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our customer care center at 1 8003484489 8. Accident claim form failure to complete all sections may result in a delay in processing this claim. Your aflac policy provides one wellness benefit per covered person, per calendar. Free accident wellness benefit claim form pdf 74kb 2. Please check this box if you are filing for a wellness benefit under multiple coverages. This form is designed to provide an annual cancer screening after the first 12 months of insurance, for those who have the cancer screening benefit.
Do not include receipts, statements or other documentation. Use only blue or black ink while completing this entire form. Aflac also provides pap smear and mammogram benefits once per year. Benefits are payable to you unless we receive written authorization from your provider to assign benefits to. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. Accidenthospital indemnity wellness benefit claim form. Continental american insurance company caic, a proud member of the aflac family. Aflac accident hospital indemnity wellness benefit claim form. Please check tm your policy for a list of covered wellness procedures or call 180099aflac 18009923522 for. This form is what you would use in the event of injury from an accident or it may be used if you have benefits that cover wellness procedures such as mammograms or pap smears.
To help provide relief for puerto rico policyholders affected by earthquakes, aflac will defer premium payments coming due for affected policyholders, starting december 28, 2019, and ending march 9, 2020. American family life assurance company of columbus aflac attn. Please complete a separate form for each individual andor calendar year. The aflac claim form is of much use when you have to claim your aflac insurance from the insurance provider. Claimantsignature familyrelationship,ifnotpolicyholder date page1of3 0708 cancer policynumber shorttermdisabilitysickness disabilityrider policynumber.
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