Transcription of New Claim Form PDFs for WEB - S00220 - Aflac
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DUCKP olicyholder Information:This * denotes a required field.*Policy Number:////------Patient Information:////Cancer Checklist Is this the initial claimfor this cancer diagnosis?NoYes (If yes, please submit the initial pathology report or examthat diagnosed cancer.) Please be sure to include the following information along with this claimform: positive Pathology Report and itemized billsfromfacility including diagnosis and/or procedure codes and charge amounts (Itemized bills may include but are notlimited to the following: UB04 fromyour provider, HCFA1500 fromyour provider, etc.) Has the patient been diagnosed with cancer?NoYes (If yes, please submit the initial pathology report or examthat diagnosed cancer.)
Title: New Claim Form PDFs for WEB - S00220 Author: Registered to: AFLAC Created Date: 8/9/2021 06:59:43
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