Transcription of New Claim Form PDFs for WEB - CW06197CA
1 CANCER SCREENING BENEFIT CLAIMFORMTo file your claimonline, register on download the MyAflac mobile app. Benefits of filing your claimonline include faster claimprocessing time and receiving claimcommunications by read all to follow these instructions could delay the processing of your Claim . Do not include receipts, statements or other claimdocumentation with this form . Do not write on formexcept as instructed. Sign, date and fax or mail the completed formto the Aflac fax number/address shown below. Use black or blue ink only and print legibly when completing this formin its entirety. Mark only wellness examboxes for test(s) and/or treatment(s) received. Failure to complete all sections may result in a delay in processing this Claim . Some types of tests and/or treatment listed may not be covered by your keep a copy of this completed formfor your records. Please print a separate formfor each additional familymember or call 1-800-99-AFLAC(1-800-992-3522) to request additional forms.
2 Claims for all other benefits coveredunder this policy must be filed separately using the claimforms available at by calling 1-800-99-AFLAC(1-800-992-3522).DUCKA merican 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 06197 CAPage 1 of 205/17 Policyholder Information:Policy Number:Patient Information:Last NameSuffixFirst NameMIDate of Birth (mm/dd/yy)Telephone Number where we can reach youHome AddressCityStateZip CodeLast NameFirst NameDate of Birth (mm/dd/yy)POLICYHOLDER/PATIENT SIGNATUREFAMILY RELATIONSHIP, IF NOT POLICYHOLDERDATEP hysician's Street AddressPhysician's CityState:Zip:Physician's NamePhysician'sPhoneNumber:Check box if this is permanent address Fields are SCREENING BENEFIT CLAIMFORMC hest X-rayScopes (Oscopies)Scans/MRIPap Smear/Pap Smear-ThinPrepHPV ScreeningActual Costof MammogramPap SmearDate:MammogramDate:Bone Marrow ScreeningCervical Cancer ScreeningCancer VaccineTreatmentDate.
3 Genetic TestingP32 Uptake TestSex:MaleFemaleRelationship:Primary PolicyholderSpouseDependent ChildMMDDYYYYA merican 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 06197 CAPage 2 of 206/17 Serum Protein ElectrophoresisHemocult Stool SpecimenCEA (blood test for colon cancer)CA125 (blood test for ovarian cancer)MammogramCA153 (blood test for breast cancer monitoring)ThermographyPSA (blood test for prostate cancer)UltrasoundsBreast UltrasoundBiopsyMMDDYYYYMMDDYYYY/-- person who knowingly and with intent to defraud any insurance company or other person files anapplication for insurance or statement of claimcontaining any materially false information or conceals forthe purpose of misleading, information concerning any fact material thereto commits a fraudulentinsurance act, which is a crime, and subjects such person to criminal and civil Physician listed above is authorized to validate the information I have provided.
