Naflac cancer claim form pdf

To prevent processing delays, please have claim form completed in full and return the signed hipaa. The plan pays a cash benefit upon initial diagnosis of a covered cancer, with a variety of other benefits payable throughout cancer treatment. Start a free trial now to save yourself time and money. Donotincludereceipts,statements,orotherdocumentationwiththisform. Aflac printable claim forms fill out and sign printable. For your protection california law requires the following to appear on this form. Authorization any person, who knowingly and with intent to defraud any insurance company, files a statement of claim containing. Claiming insurance is a much descriptive task, where you have to describe many details about your disease, disability, illness or accident etc. The aflac claim form is a form deigned to use when you are going to claim your aflac insurance. Aflac smartclaim is available for claims on most individual accident, cancer, hospital, specified health, and intensive care policies.

Use only blue or black ink while completing this entire form. You have the right to appeal a decision up to a maximum of three times per claim. Is this the initial claim for this cancer diagnosis. Cancerwellnessbenefitclaimform ifyouareinterestedinfilingyourclaimonline,smartclaim. Supporting documentation needed itemized bill if there was a hospital stay ub04 from the hospital or medical facility. Wellness and health screening claim form failure to complete all sections may result in delayed processing of this claim. 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. This benefit is payable only once for each covered person and will be paid in addition to any other. Keep a copy of the supporting documentation and this completed form for your records. Failure to sign this form will delay the processing of your claim. Aflac is not licensed to solicit business in new york, guam, puerto rico, or the virgin islands.

Accident wellness benefit claim form snohomish county. Do not include receipts, statements, or other documentation with this form. Cancer screening wellness benefit claim form please use black or blue ink only and print legibly when completing this form in its entirety. Thats why weve developed the aflac cancer care insurance policy. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. 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. Processing time is based on business days after all required documentation needed to render a decision is received and no further validation andor research is required. Failure to complete all sections may result in a delay in processing this claim.

Comments 1 employer certification for conversion of life insurance form. Fill out, securely sign, print or email your aflac accident claim form instantly with signnow. Cancer or specified disease policy instructions and. Aflac claims appeals, po box 84065, columbus, ga 319089998. Please use the claim appeal form to organize your request.

Please be sure to explain why you disagree with aflac s decision, and include any additional supporting documentation. We can only process claims in michigan benefits your way clients. Cancer claim form physicians statement american family life assurance company of columbus aflac attention. Cancer screening wellness benefit claim form patient information ca153 ceabloodtestforcoloncancer. Fill out, securely sign, print or email your aflac accident claim form cooper farms instantly with signnow. Pdf accident wellness benefit claim form aflac group insurance. The hospital or doctor will furnish this report to you at your request. 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. To avoid delays in processing of your claim form, complete each section attaching documentation below when it applies. 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. If the diagnosis of cancer was made by clinical information instead of pathological. Aflac short term disability claim form initial disability claim form.

Please complete a cancer history form provided by your agent on any individuals listed. 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. Mark only wellness claims for all other benefits covered under your cancer policy must be filed separately claim form. If you have any questions regarding benefits available, or how to file your claim, or if you. Claims department worldwide headquarters 1932 wynnton road columbus, ga 31999 for information or help filing your claim, please call tollfree 180099 aflac 18009923522 or visit our web site at aflac. Download aflac cancer screening wellness benefit claim form. Download aflac accident wellness benefit claim form pdf. While these items are typically all that is needed, we may request additional information to process your claim.

Cancer claim form instructions aflac group insurance. Yes if yes, please submit the initial pathology report or exam that diagnosed cancer. Review your policy for specific benefits covered under your plan. Aflac provides supplemental insurance for individuals and groups to help pay benefits major medical doesnt cover. You can use these cash benefits to help pay outofpocket medical expenses, the rent or mortgage. Your aflac policy provides one wellness benefit per policy year. When you use aflac smartclaim to submit accident, cancer, hospitalization or illness claims online youll get paid fast. Fax us anytime, even outside of our regular business hours. 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. Fill out, securely sign, print or email your aflac long care continuing claim form instantly with signnow. Processing time is based on business days after all required documentation needed to render a decision is received and no further validation andor.

Your aflac new york policy provides one wellness benefit per covered person, per calendar year, and this. If you are interested in filing your claim online, register using smartclaim. Cancer claim form instructions cancer claim please complete the policyholderclaimant information section below. If you are filing for benefits under a lumpsum cancer policy, which provides a predetermined amount upon the positive diagnosis. Your aflac policy provides one wellness benefit per covered person, per calendar year, and this form is. Claims department, worldwide headquarters, 1932 wynnton road, columbus, ga 31999, as soon as possible in order to expedite. Fax this form to 18774423522 or return the form to aflac, attn. Mark only wellness exam boxes for tests that you had performed. Have your attending physician complete the section on the reverse side of the form that corresponds to the specific critical illness for which the claim is being made. It is imperative that you attach a copy of the pathology report used in the diagnosis of cancer. Personal cancer indemnity plan cancer insurance only. Aflac also provides pap smear and mammogram benefits once per year. Pathology report from your doctor, if your claim is for cancer.