Benefits Your Way - AFLAC Claim FormsItemized bill from physician’s office (HCFA from physician’s office) Pathology report or exam with diagnosis, if this is the first claim. Itemized bill for chemotherapy or radiation, if services were provided. If for the Lump Sum Cancer Plan, submit a copy of the patient’s birth certificate. The above example is based on a scenario for Aflac Cancer Care – Classic that includes the benefit conditions: Physician visit (Cancer Wellness Benefit) of $75, bone marrow biopsy (Surgical/Anesthesia Benefit) of $, NCI Evaluation/Consultation Benefit of $, Initial Diagnosis Benefit of $4,, venous port. CRITICAL ILLNESS WELLNESS BENEFIT CLAIM FORM INSTRUCTIONS Please use black or blue ink only and print legibly when this form in its entirety. Keep a copy of the documentation and this completed form for your records. Sign, date, and mail or fax the completed form to the address/number shown below. Do not include receipts, statements or other documentation with this form. Your Aflac policy provides one Wellness Benefit per policy year. Please note that these benefits are not payable for treatment within the first 12 months of the policy’s effective date. To receive your Wellness Benefit, complete the form by the instructions. Hospital Intensive Care Protection Insurance Policy Series A Hospital Intensive Care Unit Benefit Aflac will paythe benefits when a covered person incurs a charge for confinement in a hospital intensive care unit or a step-down intensive care unit for a covered sickness or injury: Confinement in a Hospital Intensive Care Unit. ˜ Complete Section A: Policyholder/Patient Information and sign your claim form. ˜ Have the physician complete Section B: Physician's Statement and sign the claim form. ˜ If you are for disability, please complete the Initial Disability Claim Form (S) as well. Forms are available on our web site at kdomh.linkpc.net OUTPATIENT PHYSICIAN’S TREATMENT CLAIM FORM If you have any questions benefits available, or how to file your claim, or if you would like to appeal any determination, please contact our Customer Care Center at , A.M. to P.M. Eastern Standard Time or visit our website at kdomh.linkpc.net Download Aflac Cancer Wellness Benefit Claim Form. This form is designed to provide an annual cancer (after the first 12 months of insurance), for those who have the Cancer Benefit. Aflac also provides pap smear and mammogram benefits once per year. Use only blue or black ink while this entire form. Policyholder Signature Printed Name Date Date of Physician's Visit: • Please complete all sections of the form, sign, date, and mail form to the address shown below. • Do not fax or photocopy this document. • Submit only one treatment date per claim form. • Incomplete forms will be returnedfor completion. • Each additional treatment date should be on a separate.
PolicyholderInformation: PolicyNumber: PatientInformation: AllFieldsarerequired. DateofPhysician’sVisit: *PleasesubmitonlyFile Size: 54KB. If you disagree with a claims decision, you may submit an appeal, policy provisions: Mail: Aflac Claims Appeals, PO Box , Columbus, GA 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 documentation. Policyholder Signature Printed Name Date Date of Physician's Visit: • Please complete all sections of the form, sign, date, and mail form to the address shown below. • Do not fax or photocopy this document. • Submit only one treatment date per claim form. • Incomplete forms will be returnedfor completion. • Each additional treatment date should be on a separateFile Size: 65KB.
Your major medical coverage may be more or less, and if an individual or family incurs expenses for non-covered benefits, these out-of-pocket expenses may increase potential unexpected costs. Aflac claims are usually processed fairly quickly. Support Center Templates. Policies have limitations and exclusions that may affect benefits payable. Your use of this site is subject to Terms of Service. Get started. Benefits payable are determined at time of claim. Find the care you need to help maintain healthy vision. Ready to take the next step to protect your future? Benefits are payable at the time a claim is processed. These days no one can afford to not be protected against financial fallout from injury or illness. Please note, it can take up to two business days to process your request. Watch the video.