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