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CRITICAL ILLNESS CLAIM FORM INSTRUCTIONS
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HIPAA-AUTHORIZATION TO OBTAIN INFORMATION
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Wellness Claim Form - Aflac: Supplemental Insurance for ...
www.aflacgroupinsurance.comAny information obtained wil not be released by Continental America Insurance Company to any person or organization EXCEPT to re -insuring companies, or other person or organizatoi n performng business or legal services in connectoni with any
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 …
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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