New Claim Form PDFs for WEB - S00220 - Aflac

1 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.) Type of cancer: Date of initial diagnosis:// First date of treatment for this diagnosis://American 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) S00220 Page 1 of 202/14*Last NameSuffix*First NameMI*Date of Birth (mm/dd/yy)Telephone Number where we can reach you*Home Address*City*State*Zip Code*Last Name*First Name*Date of Birth (mm/dd/yy)*Sex:MaleFemale*Relationship:P rimary PolicyholderSpouseDependent ChildCheck box if this is a permanent address CLAIMFORMT hank you for trusting Aflac with your Cancer needs.

2 If you are interested in filing your claimonline or uploading documentation on an existing Claim , register prevent delays, please provide documentation fromyour healthcare provider to support this Claim . If you haveadditional bills or medical documentation that relates to this diagnosis other than the documentation defined, pleasesubmit themfor review of additional benefits. Service related items can be obtained directly fromthe patient s healthcare provider(s) by requesting a UB04hospital bill or HCFA 1500 non-hospital bill. Failure to complete all sections may result in a delay in processing this Claim . Disclaimer: Some of the services listed may not be covered by your you have additional bills or medical documentation that relates to this diagnosis other than the documentationdefined, please submit themfor review of additional Information:*Policy Number:Patient Information://// Was the patient confined to the hospital as a result of this diagnosis?

3 NoYes (If yes, please submit the itemizedhospital bill, UB04 fromyour provider, or HCFA 1500 fromyour provider.)Hospital nameCityState Please provide the name, address and phone number of the patient s primary treating :Phone Number:Address: Was the patient treated by any other physicians?NoYesIf yes, physician s name(s):Phone Number(s):Address: Did the patient undergo surgery for this condition?NoYes (If yes, please submit a copy of the operative report,surgeon s bill and anesthesia bill to include charges.)Where was the surgery performed?OfficeSurgical CenterOutpatient HospitalInpatient HospitalName of facility:Address: Has the patient received chemotherapy?NoYes (If yes, please submit a copy of itemized billing.)Name of facility where chemotherapy was received:Address: Has the patient received oral chemotherapy?NoYes (If yes, please submit pharmaceutical statements.)

4 Has the patient received topical chemotherapy (Treatment with anticancer drugs in a lotion or creamapplied to the skin)?NoYes (If yes, please submit pharmaceutical statements.) Has the patient received radiation therapy?NoYes (If yes, please submit a copy of itemized billing.)Name of facility where radiation was received:Address: Transportation/Lodging Information: To be completed if you are filing a claimfor transportation or lodging: (please submitthe hotel receipts and mileage information) *For additional information, please refer to your policy language.*Last NameSuffix*First NameMI*Date of Birth (mm/dd/yy)*Last Name*First Name*Date of Birth (mm/dd/yy)Any 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 Family Life Assurance Company of Columbus ( Aflac )ATTN.

5 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) S00220 Page 2 of 202/14 POLICYHOLDER/PATIENT SIGNATUREFAMILY RELATIONSHIP, IF NOT POLICYHOLDERDATEDateTo/FromRound-Trip MileageType of Treatment