Cancer screening wellness benefit claim form some of the tests listed may not be covered under the wellness benefit of your policy. Cancer or specified disease policy instructions and checklist for submitting a claim claims customer service. The aflac claim form is of much use when you have to claim your aflac insurance from the insurance provider. Your aflac policy provides one wellness benefit per policy year. Your aflac policy provides one wellness benefit per covered person, per calendar year, and this form is. Failure to follow these instructions will delay the processing of your claim. Claim forms and other valuable information may be found on. The way to complete the online aflac claim forms on the internet. Aflac printable claim forms fill out and sign printable pdf. Claims department worldwide headquarters 1932 wynnton road columbus, ga 31999 for information or help filing your claim, please call tollfree 180099aflac 18009923522 or visit our web site at.
To receive your wellness benefit, complete the form by following the instructions. When you use aflac smartclaim to submit accident, cancer, hospitalization or illness claims online by 3 p. 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. 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. Duck your aflac policy provides one eye exam benefit per covered person per policy year, and this. Use this stepbystep instruction to complete the aflac claim form quickly and with excellent accuracy. Continental american insurance company 2801 devine street columbia, south carolina 29205 18004333036 tollfree 18668492970. Wellness and health screening claim form failure to.
The hospital or doctor will furnish this report to you at your request. Cancer screening wellness benefit claim form please use black or blue ink only and print legibly when completing this form in its entirety. Life claim forms for the state of illinois must be obtained by contacting aflac worldwide headquarters at 800. Claiming insurance is a much descriptive task, where you have to describe many details about your disease, disability, illness or accident etc. Our customer service representatives are here to assist you monday through friday from 8 a. For groups sitused in new york, coverage is underwritten by american family life assurance company of new york. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. A pathology report documenting the cancer diagnosis is required for claim processing. S2029ca american family life assurance company of columbus aflac. Your local aflac insurance agentproducer american family life assurance company of columbus aflac worldwide headquarters 1932 wynnton road columbus, georgia 31999 1. Do not include receipts, statements, or other documentation with this form. Please note that these benefits are not payable for treatment within the first 12 months of the policys effective date.
Claimantsignature familyrelationship,ifnotpolicyholder date page1of3 0708 cancer policynumber shorttermdisabilitysickness disabilityrider policynumber. Your aflac new york policy provides one wellness benefit per covered person, per calendar year, and this. Continental american insurance company 2801 devine street columbia, south carolina 29205 18004333036 tollfree 18668492970 fax caieft14v1. This benefit is payable only once for each covered person and will be paid in addition to any other.
Aflac claim forms fill out and sign printable pdf template. Keep a copy of the supporting documentation and this completed form for your records. The aflac claim form is a form deigned to use when you are going to claim your aflac insurance. Failure to complete all sections may result in delayed processing of this claim. Benefits are payable to you unless we receive written authorization from your provider to assign benefits to them or from you to pay your benefits elsewhere. A new claim form will be sent to you when any claims payment is made. Do not include receipts, statements, or other documentation. American family life assurance company of columbus aflac worldwide headquarters 1932 wynnton road columbus, georgia 31999 1. S00198ca failure to complete this form in its entirety may result in a delay in processing this claim.
Wellness and health screening claim form failure to complete. Critical illness health screening form failure to complete all sections may result in a delay in processing this claim. Preparation of bills attach your itemized hospital bills and submit this claim form. 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. Download aflac cancer screening wellness benefit claim form. Failure to complete this form in its entirety may result in a delay in processing this claim. Aflac short term disability claim form initial disability claim form. Failuretofollowtheseinstructionscoulddelaytheprocessingofyourclaim.
Review your policy for specific benefits covered under your plan. Mark only wellness exam boxes for tests that you had. You may either write a lengthy letter to make your claim, or you may fill the easy. To file a claim, simply select the appropriate claim form for your specific product and mail or fax it to us at the address on the form. This form is designed to provide an annual cancer screening after the first 12 months of insurance, for those who have the cancer adobe pdf. To avoid delays in processing of your claim form, complete each section attaching documentation below when it applies. Supporting documentation needed itemized bill if there was a hospital stay ub04 from the hospital or medical facility. Start a free trial now to save yourself time and money. Continental americ an insurance company 1600 williams st columbia, south carolina 29201 18004333036 tollfree 18668492970 fax. Accident wellness benefit claim form do not write on form except as instructed. Mark only wellness exam boxes for tests that you had performed. Supporting documentation needed itemized bill if there was a hospital stay. Friday to help us process your claim as quickly as possible, you must provide us with all the necessary information.
Policyholderpatientsignature familyrelationship,ifnotpolicyholder date checkboxifthisispermanentaddresschange. Cancer claim form for your protection california law requires the following to appear on this form. Do not include receipts, statements or other documentation. One day pay sm is available for certain individual claims submitted online through the aflac smartclaim process. Aflac also provides pap smear and mammogram benefits once per year. Donotincludereceipts,statements,orotherdocumentationwiththisform. Accident wellness benefit claim form failure to complete all sections may result in a delay in processing this claim. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Incomplete forms cannot be processed and will be returned. If the diagnosis of cancer was made by clinical information instead of pathological means, please submit the clinical evidence that established a positive diagnosis of cancer. Use only blue or black ink while completing this entire form. Cancer or specified disease policy instructions and check. Claims department, worldwide headquarters, 1932 wynnton road, columbus, ga 31999, as soon as. Personal cancer indemnity plan cancer insurance only.
The f acts say y ou need the pro tection of aflacs cancer care plan. To prevent processing delays, please have claim form completed in full and return the signed hipaa. 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. Cancerwellnessbenefitclaimform ifyouareinterestedinfilingyourclaimonline,smartclaim. Cancer or specified disease policy instructions and. Vision nowsm eye examvision correction materials claim form do not write on form except as instructed. Do not include receipts, statements or other documentation with this form. Accident claim form failure to complete all sections may result in a delay in processing this claim. Aflac printable claim forms fill out and sign printable. We care about aflacs policyholders affected by the recent severe weather. Aflac is not licensed to solicit business in new york, guam, puerto rico, or the virgin islands. Cancerannualcarebenefitclaimform pleasereadallinstructions. The facts sa y y ou need the pro tection of aflacs cancer care plan. The advanced tools of the editor will direct you through the editable pdf template.
Fax this form to 18774423522 or return the form to aflac, attn. Fill out, securely sign, print or email your aflac accident claim form cooper farms instantly with signnow. Claims may be eligible for one day pay processing if submitted online through aflac smartclaim, including all required documentation, by 3 p. Any person who knowingly and with intent to defraud any insurance company, files a statement of claim containing any.