WELLNESS AND HEALTHSCREENING CLAIM FORM Failure to ...
Flexible Sigmoidoscopy Hemoccult Stool Analysis HIV (Human Immunodefiency) HPV (Human Papillomavirus) HSN Strains Human Coronavirus Testing Immunizations Mammograms Non-Diagnostic Vascular Screening Pap Smears PSA Test Serum Cholesterol Test Serum Protein Skin Cancer Screening Spinal CT Screening Stress Test on Bicycle or Treadmill …
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Supplemental Hospital and Medical Indemnity Claim …
www.aflacgroupinsurance.comPost Office Box 84075 Columbus, Georgia 31993 Phone-(866)849-2964 Fax-(866-849-2974 Phone (866)849-2964 Supplemental Hospital and Medical Indemnity Claim Instructions
SUPPLEMENTAL CLAIM FORM (CONTINUING DISABILITY)
www.aflacgroupinsurance.comCONTINENTAL AMERICAN INSURANCE COMPANY Post Office Box 84075 * Columbus, GA. 31993 Phone (800) 433-3036 * Fax (866) 849-2970 . SUPPLEMENTAL CLAIM FORM (CONTINUING DISABILITY)
CRITICAL ILLNESS CLAIM FORM INSTRUCTIONS
www.aflacgroupinsurance.comHealth information maybe disclosed by any health care provider, health plan (including CAIC or Aflac, with respect to other CAIC or Aflac coverages) or health care
HOSPITAL INDEMNITY CLAIM FORM INSTRUCTIONS
www.aflacgroupinsurance.comHOSPITAL INDEMNITY CLAIM FORM INSTRUCTIONS . To avoid delays in processing of your claim form, complete each section attaching documentation below whenit applies. Supporting Documentation Needed Itemized bill if there was a hospital stay …
SHORT TERM DISABILITY CLAIM FORM INSTRUCTIONS
www.aflacgroupinsurance.comSHORT TERM DISABILITY CLAIM FORM INSTRUCTIONS . To avoid delays in processing of your claim form, complete each section attaching documentation belowwhen it applies. Note: This form is for initial filing of a disability claim. If your disability is being extended, you will need to complete the listed Supplemental Claim form.
Insuring Over 40 Million People Worldwide
www.aflacgroupinsurance.comIf you have any questions, please contact our Customer Service Center at 1-800-433-3036, Monday through Friday from 8 a.m. to 8 p.m. Eastern time. For Home Office Use Only <Name> #<certificate number>
CRITICAL ILLNESS CLAIM FORM (Page 1 of 2)
www.aflacgroupinsurance.comAflac Group Critica Illlness Claim Form _2020 . Post Office B ox 84075 * Columbus, GA. 31993 . Phone (800) 433 -3036 * Fax (866)849-2970 . [email protected] . CRITICAL ILLNESS CLAIM FORM (Page 1 of 2) ATTENDING PHYSICIAN’S STATEMENT . PATIENT’S FIRST …
HIPAA-AUTHORIZATION TO OBTAIN INFORMATION
www.aflacgroupinsurance.comFamily Life Assurance Company of Columbus and American Family Life Assurance Company of New York (collectively, “Aflac). ... Health information may also be disclosed by any insurance company or the Medical Information Bureau (MIB). Health information ... (2) years from the date signed or upon my death, whichever occurs first. I agree that a
Disability Claim Filing Instructions
www.aflacgroupinsurance.cominformation in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. California – For your protection California law requires the following to appear on this form: “Any person who knowingly presents …
CONTINENTAL AMERICAN INSURANCE COMPANY Dental …
www.aflacgroupinsurance.comDental Claim Form ©American Dental Association, 1999 version 2000 ©American Dental Association, 1999 1. Dentist’s pre-treatment estimate Dentist’s statement of actual services Specialty (see backside) 3. Carrier Name 2. Medicaid Claim 4. Carrier Address EPSDT Prior Authorization # 5. City 6. State 7. Zip 8. Patient First Name 9. Address ...
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www.cigna.com_____Flexible Sigmoidoscopy . with possible biopsy and/or polypectomy with possible use of (pt initials) electrocautery. This examination involves the passage of a shorter, flexible instrument through the rectum to view the lining of the lower large bowel with possible moderate sedation.
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www.cigna.comflexible sigmoidoscopy) › Depression screenings › Diabetes screenings › Diabetes self-management training › Glaucoma tests › Hepatitis B Virus (HBV) infection screening › Hepatitis C screening › HIV screening › Lung cancer screening with low dose computed . tomography (LDCT) › Medical nutrition therapy services › Obesity ...
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www.lahey.orgFlexible Sigmoidoscopy . 6 CENTRAL . Executive Health . 4 SOUTHEAST . Exercise Tolerance Testing . 5 CENTRAL . Family Waiting Room (SICU) 2 EAST . Family Waiting Room (Surgical) 2 CENTRAL . Gastroenterology . 6 CENTRAL . General Internal Medicine . 67 S. Bedford St. General Surgery . 6 CENTRAL . Gift Shop . MAIN LOBBY . Gynecology .
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www.modahealth.comSigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation) 45346 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) 453 47 Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre- and post-
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