Transcription of PDF forms for web - Aflac
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PDF forms for web - Aflac
CONTAGIOUS DISEASE/OUTPATIENT SURGERY CARE BENEFIT CLAIMFORMP lease refer to your policy to verify your eligibility for this benefit. Failure to complete all sections may result in a delay in processing this claim. Please complete all fields, sign, date and mail or fax the completed formto the Aflac address/fax number shownbelow. Please use black or blue ink only and print legibly when completing this formin its entirety. Indicate each individual date (up to ten days) you missed work to provide care in the labeled boxes.**If filing for more than five days, information must be verified with your employer and/or Family Life Assurance Company of Columbus ( Aflac )ATTN: Claims Department 1932 Wynnton Road Columbus, GA31999 For information or to check claimstatus, visit call 1-800-99- Aflac (1-800-992-3522)Claims may be faxed to 1-877-44- Aflac (1-877-442-3522)CW M1204 CDPage 1 of 202/14 Policyholder Information:Policy Number:Patient Information:Check box if this is permanent address :Physician Information:All Fields are NameSuffixFirst NameMIDate of Birth (mm/dd/yy)Telephone Number where we can reach youHome AddressCityStateZi
CONTAGIOUSDISEASE/OUTPATIENTSURGERYCAREBENEFITCLAIMFORM Pleaserefertoyourpolicytoverifyyoureligibilityforthisbenefit. ...
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