New Claim Form PDFs for WEB - S2029

1 Of Claim decision:Date of Claim decision is the date listed on your denial letter or Explanation of Benefits of loss:American Family Life Assurance Company of Columbus (Aflac) ATTN: Claims Appeals PO Box 84065 Columbus, GA 31908 For information or to check Claim status, visit Appeals may be faxed to 1-888 659-1023 Page 1 of 3 HC0021 06/19 Claim APPEAL FORM Today's Date: Thank you for trusting Aflac with your supplemental insurance needs. The appeal must be filed within 180 days of a claims decision. You may file up to 3 appeals per Claim . Please provide documentation from your health care provider to support this appeal. If you have additional bills ormedical documentation that relate to this diagnosis, please submit it along with this form. Supportingdocumentation includes but is not limited to: UB04 hospital bill, CMS 1500 non-hospital bill, physician office notes,emergency room reports and other medical records to support your appeal.

2 A decision will be issued within 45 days* from the date all required information is received by Aflac. Not providingall required information may delay processing of your appeal. No new claims should be submitted with this form. Please submit a separate form for each appeal. Disclaimer: Submission of this form does not guarantee approval. You may send your appeal, citing supporting policy provisions, in writing to fax number 888-659-1023, or mail toAflac Claims Appeals, PO Box 84065, Columbus, GA 31908-9998. Use this form for your Information: This * denotes a required field . *Policy Number(s):_____* Claim Number(s):_____List all policy and/or Claim numbers associated with this *Last NameSuffix*First NameMI*Date of Birth (mm/dd/yy)Telephone Number where we can reach you*Home Address*City*State*Zip CodePatient Information:*Last Name*First Name*Date of Birth (mm/dd/yy)*Sex:Male*Relationship:FemaleP rimary PolicyholderSpouseDependent ChildCheck box if this is a permanent address for RequestIf possible, please provide additional details about your Claim :The date of loss is the date of the accident, date symptoms first occurred, date of diagnosis Family Life Assurance Company of Columbus (Aflac) ATTN: Claims Appeals PO Box 84065 Columbus, GA 31908 For information or to check Claim status, visit Appeals may be faxed to 1-888 659-1023 Page 2 of 3 HC0021 06/19 Claim APPEAL FORM explain why you disagree with the Claim decision.

3 If possible, please provide the policy provision thatsupports your appeal. (Attach additional pages if necessary.):DUCKCLAIM APPEAL FORM STATE LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: AZ "For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent Claim for payment of a loss is subject to criminal and civil penalties." CA "For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent Claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison." CO "It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages.

4 Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies." DC "WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a Claim was provided by the applicant." FL "Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

5 KY "Any person who knowingly and with intent to defraud any insurance company or other person files a statement of Claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime." NJ "Any person who knowingly files a statement of Claim containing any false or misleading information is subject to criminal and civil penalties. " NY, CT, MA "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of Claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars ($5,000) and the stated value of the Claim for each such violation.

6 " PR "Any person who, knowingly and with intent to defraud, presents false information in an insurance request form, or who presents, helps or has presented a fraudulent Claim for the payment of a loss or other benefit, or presents more than one Claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand ($5,000) dollars or more than ten thousand ($10,000) dollars, or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if extenuating circumstances prevail, it may be reduced to a minimum of two (2) years." All other states "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of Claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and subjects such person to criminal and civil penalties.

7 " POLICYHOLDER/PATIENT SIGNATURE FAMILY RELATIONSHIP, IF NOT POLICYHOLDER DATE American Family Life Assurance Company of Columbus (Aflac) ATTN: Claims Appeals PO Box 84065 Columbus, GA 31908 For information or to check Claim status, visit Appeals may be faxed to 1-888 659-1023 Page 3 of 3 HC0021 06/19 DUCK*If your Aflac policy is subject to ERISA, the following review process applies: If a Claim for benefits payment under the policyis denied in full, you or your authorized representative may appeal that denial within 180 days of the date you receive thisnotice. You have the right to submit new information with your request. You may request copies of records relevant to yourclaim. You will be notified of Aflac s final decision on the appeal within 60 (45 for disability claims) calendar days after receiptof your request for review. You have the right to bring a civil action under section 502(a) of ERISA following a denial of 5/16 Claims Authorization to Obtain InformationInstructions for completing this Health Insurance Portability and Accountability Act of 1996(HIPAA) compliant areas of this formshould be formmust be signed and dated by the claimant/patient : If you are filing a claimon behalf of a deceased, please check here you are the Authorized Representative, please sign below and indicate your relationship to theclaimant/patient/deceased.

8 In addition, include a copy of the legal document(s) authorizing you toact on their this formto 1-877-442-3522 or return the formto Aflac, Attn: Claims Department, WorldwideHeadquarters, 1932 Wynnton Road, Columbus, GA 31999, as soon as possible in order to Name:Policy Number(s):Date of Birth:Policyholder Address:Claimant/Patient Name (if different fromnamed policyholder listed above):Date of Birth:American Family Life Assurance Company of Columbus (Aflac)Worldwide Headquarters 1932 Wynnton Road Columbus, Georgia 319991-800-992-3522 of claimant/patient, guardian or authorized representativeDatePrinted name of claimant/patient, guardian or authorized representativeRelationshipI understand health information may include information and records protected under Federal and State Lawsuch as: alcohol, drug abuse, mental health, AIDS or HIV testing or treatment, or the presence of acommunicable or noncommunicable treatment, payment or eligibility for benefits may not be conditioned on signing this understand that I may revoke this authorization at any time by writing toAflac, Claims Department,Worldwide Headquarters, 1932 Wynnton Road, Columbus, GA 31999, except to the extent has taken action in reliance to this authorization, law provides Aflac with the right to contest a claimunder the policy or the policy the requestor or receiver is not a health plan or health care provider, the released information may nolonger be protected by federal privacy regulations and may be is recommended I retain a copy of this signed formfor my records, understanding that a copy is as validas the residents of AZ, CA, CT, GA, IL, ME, MA, MN, NV,NJ, NM, NC, OH, and VA.

9 This authorization will be validfor a period of two years fromthe sign date or until thetermination of the policy coverage, whichever is less,unless a lesser alternate expiration date is provided residents of all other States,this authorization will bevalid for a period of two years fromthe sign date, unless alesser alternate expiration date is provided Expiration Date:Name and Address of health care provider(s),company, or individual authorized to releasethe requested information:(this section will be completed by Aflac):Purpose of Disclosure:Evaluate claims for benefitsduring the time this authorization is , or my authorized representative, request that information regarding my past, present, or future physical ormental health condition (excluding psychotherapy notes), employment, other insurance coverage, or any othernonmedical facts be released toAmerican Family Life Assurance Company of Columbus (Aflac)or anyperson or entity acting on its part.

10 This could include, but is not limited to, any medical professional, medicalcare institution, insurer (including Aflac, with respect to other Aflac coverages), reinsurer, government agency(including departments of public safety and motor vehicle departments), consumer reporting agency oremployer.