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. See your policy for additional wellness benefit information. Please complete this section of the claim form and mail or fax the. The member is responsible for payment to the service provider in the event the claim is denied or if plan benefits have been exceeded. Critical illness wellness benefit claim form aflac. This form is used for either the group cancer or group critical illness plans.
Please use black or blue ink only and print legibly when completing this form in its entirety. Critical illness wellness benefit claim form failure to complete all sections may result in a delay in processing this claim. Please use the claim appeal form to organize 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. Watch this stepbystep video to see how to file a claim online. This optional benefit may be available for an additional premium.
Your aflac policy provides one wellness benefit per policy year. American family life assurance company of columbus aflac. Instructions for filing wellness claims to avoid delays in processing please fill out the sections which apply to your specific claim. Please note that these benefits are not payable for treatment within the first 12 months of the. Claim forms and other valuable information may be found on 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 18003484489 8. The type of health screening that was performed, date of service and copy of bill. Wellness and health screening claim form failure to. If you were treated at a noncost incurred facility. Please fully complete the claim form for the wellness benefit. Critical illness wellness benefit claim form send to. Download aflac cancer screening wellness benefit claim form. Group accidental injury critical illness health screening. Aflac wellness claim forms printable fill online, printable, fillable. 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.
Benefit periods and type of screenings covered may vary by type of policy. Accidenthospital indemnity wellness benefit claim form. Sign, fax and printable from pc, ipad, tablet or mobile with pdffiller. Please keep a copy of this completed form along with the supporting documentation for your records.
Group accidental injurycritical illness health screening and wellness visit benefits proof of loss. Authorization any person, who knowingly and with intent to defraud any insurance company, files a statement of claim containing. Failure to complete this form may cause a delay in the processing of your claim. Except as noted in the separate fraud notice, any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Wellness benefit claim form submitting a wellness claim to file for your wellness benefit claim, complete this form, front and back, in full.
Select the form for the expenses you wish to submit and provide any necessary information as instructed on the form. 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. You have the right to appeal a decision up to a maximum of three times per claim. Under the download a claim form heading, users select a state from the dropdown menu and click submit. Users select a wellness benefit claim form from the available. Your aflac policy provides one wellness benefit per covered person, per calendar year, and this form is designed specifically for this benefit. Claim form and instructions 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 18003484489 8. Do not attach more than one family members receipts to one claim form. Review your policy for specific benefits covered under your plan. Health screening tests include but are not limited to the following. Aig you are eligible to receive the amount shown in your schedule of benefits per calendar year per insured if you have a health screening test.
If you are interested in filing your claim online, register using smartclaim. 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. Wellness benefit claim form clmformwellsigned authorization to obtain medicalconfidential information see attached formsigned itemized medical bills for tests or procedures or evidence of wellness visit where to submit claims. Critical illness wellness benefit claim form instructions please use black or blue ink only and print legibly when completing this form in its entirety. Aflac is not licensed to solicit business in new york, guam, puerto rico, or the virgin islands. Keep a copy of the supporting documentation and this completed form for your records. Is aflacs wellness benefit claim form available online.
Please be sure to explain why you disagree with aflacs decision, and include any additional supporting documentation. Accident wellness benefit claim form yes prep benefits. Aflac indemnity form aflac wellness claim forms printable. Aflac claims appeals, po box 84065, columbus, ga 319089998. Please be sure to explain why you disagree with aflac s decision, and include any additional supporting documentation. Cancerwellnessbenefitclaimform ifyouareinterestedinfilingyourclaimonline,smartclaim. Pharmacy, ambulance andor hospital room charges only. Please check this box if you are filing for a wellness benefit under multiple coverages. Any person, who knowingly and with intent to defraud any insurance company.
Mark only wellness exam boxes for tests that you had performed. Wellness and preventive reimbursement claim form sept 2014. Use only blue or black ink while completing this entire form. Aflac also provides pap smear and mammogram benefits once per year. Remember it is a crime to fill out this form with facts you know are false or. Please date and sign all required forms where indicated. Completely fill out part one of the wellness and preventive reimbursement claim form and attach your receipts. Policynumber thermography for your protection california law requires the following to appear on this form. Sign, date, and mail or fax the completed form to the addressnumber shown below. If you have any questions regarding benefits available, or how to file your claim, or if you. Wellness claims are available as part of the group cancer or critical illness policies see the attached wellness claim form. Do not include receipts, statements, or other documentation with this form. Wellness and health screening claim form failure to complete all sections may result in delayed processing of this claim. Your aflac policy provides one wellness benefit per covered person, per calendar year, and this form is.
Please check your policy for a list of covered wellness procedures or call 1800 99aflac 18009923522 for a. I am able to modify the forms to fit my special needs and requirements. Wellness benefit claim form benefits may be delayed if claim form is not fully completed please complete the information on the claim form below and submit a copy of the bill. File colonial life insurance claim forms colonial life. Preventive care benefit claim form you are eligible to receive the amount shown in your schedule of benefits per calendar year per insured if you have a health screening test. You will have a choice of one of the 23 different wellness screening test available per covered personper year.
Simply call 18003254368, and one of our specialists will take care of you. Accident wellness benefit claim form instructions please use black or blue ink only and print legibly when completing this form in its entirety. 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. Download aflac accident wellness benefit claim form pdf. If you were treated at a noncost incurred facility, please furnish verification from that facility of. Claims for all other benefits covered under your cancer policy must be filed separately, using the.
Mark only wellness exam boxes for tests andor treatments received. Preventive care benefit claim form american general life insurance company the united states life insurance company in the city of new york a member of american international group, inc. To receive your money even faster, login to your account and enroll in direct deposit. Accident wellness benefit claim form failure to complete all sections may result in a delay in processing this claim. Fill aflac wellness claim forms printable, edit online. When submitting a claim, attention to the following details will assure that your claim moves quickly and benefits due are processed without delay. Hospital indemnity plan wellness benefit claim form failure to complete all sections may result in a delay in processing this claim. Health screening benefit claim form wellness benefit claim form the benefits center p. Incomplete or illegible answers may result in a delay of benefit consideration. Services must incur a charge and be supervised or recommended by a physician. Send to guardian life insurance, critical illness claims, po box 14334, lexington, ky 40512 customer service. Simply select file online below and follow the instructions. Send to guardian life insurance, accident claims, po box 14315, lexington, ky 40512.
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