To prevent delays, please provide documentation from your healthcare provider to support this claim. The way to complete the online aflac accident hospital indemnity wellness benefit claim form on the internet. Some of the tests listed may not be covered under the wellness benefit of your policy. Register and login below to file an aflac smartclaim. You could suffer an accidental injury while you are working around the house or walking into work. Ny0784 american family life assurance company of new york aflac new york ny0784. Please note that these benefits are not payable for treatment within the first 12 months of the policys effective date.
Claims department, worldwide headquarters, 1932 wynnton road, columbus, ga 31999, as soon as possible in order to expedite claim. Your aflac policy provides one wellness benefit per covered person, per calendar year, and this form is. Enter your official identification and contact details. Claims department, 1932 wynnton road, columbus, ga, 31999. Your aflac new york policy provides one wellness benefit per covered person, per calendar year, and this.
Wellness claim form if you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our customer care center at 1 8003484489 8. Or your child may get injured at basketball practice. Please use black or blue ink only and print legibly when completing this form in its entirety. Mark only wellness exam boxes for tests that you had performed. Incomplete forms cannot be processed and will be returned. Cancer screening wellness benefit claim form some of the tests listed may not be covered under the wellness benefit of your policy. Accident claim form failure to complete all sections may result in a delay in processing this claim. Claimantsignature familyrelationship,ifnotpolicyholder date page1of3 0708 cancer policynumber shorttermdisabilitysickness disabilityrider policynumber. Please sign the attached hipaa form and return it with the completed claim form. If you disagree with a claims decision, you may submit an appeal, citing supporting policy provisions. American family life assurance company of columbus aflac. Aflac wellness claim forms printable fill online, printable, fillable. Please be sure to explain why you disagree with aflac s decision, and include any additional supporting documentation.
Do not include receipts, statements or other documentation with this form. Now is the time to learn more about aflac s online selfservice tools. This form is designed to provide an annual cancer screening after the first 12 months of insurance, for those who have the cancer screening benefit. Users select a wellness benefit claim form from the available choices, and click on the corresponding link to download the document. Hence, the form is also a lengthy one, and contains many fields to accumulate all necessary details. Watch this stepbystep video to see how to file a claim online. For groups sitused in new york, coverage is underwritten by american family life assurance company of new york.
Your aflac policy provides one wellness benefit per policy year. Fill aflac wellness claim forms printable, edit online. Please complete a separate form for each individual andor calendar year. Claims department worldwide headquarters 1932 wynnton road columbus, ga 31999 for information or help filing your claim, please call tollfree 180099 aflac 18009923522 or visit our web site at aflac. Users complete, sign and date the form, and mail it to american family life assurance company of columbus aflac, attn. Sign, date, and mail or fax the completed form to the addressnumber shown below. Be prepared for lifes unexpected mishaps accidents can happen at any time. Download aflac cancer screening wellness benefit claim form. Accident wellness benefit claim form snohomish county. Use only blue or black ink while completing this entire form. Do not include receipts, statements or other documentation.
Claims for all other benefits covered under your policy must be filed separately using the appropriate claim form. Register and login to myaflac to file a claim in your time of need. Your aflac policy provides one wellness benefit per covered person, per calendar year, and this form is designed specifically for this benefit. Fax this form to 18774423522 or return the form to aflac, attn. Do not include receipts, statements, or other documentation with this form. Keep a copy of the supporting documentation and this completed form for your records. Download aflac accident wellness benefit claim form pdf. Wellness and health screening claim form failure to. Accident wellness benefit claim form some of the tests listed may not be covered under the wellness benefit of your policy. The aflac claim form is a form deigned to use when you are going to claim your aflac insurance.
Accidenthospital indemnity wellness benefit claim form. During these trying times, aflac wont let social distancing prevent you from getting paid. Is aflacs wellness benefit claim form available online. Critical illness wellness benefit claim form instructions please use black or blue ink only and print legibly when completing this form in its entirety.
Failure to complete all sections may result in delayed processing of this claim. American family life assurance company of columbus aflac attention. Pdf accidenthospital indemnity wellness benefit claim. Continental american insurance company caic, a proud member of the aflac family of insurers, is a whollyowned subsidiary of aflac incorporated and underwrites group coverage. Cancer screening wellness benefit claim form please use black or blue ink only and print legibly when completing this form in its entirety. The advanced tools of the editor will direct you through the editable pdf template. Claiming insurance is a much descriptive task, where you have to describe many details about your disease, disability, illness or accident etc. This form is what you would use in the event of injury from an accident or it may be used if you have benefits that cover wellness procedures such as mammograms or pap smears. To receive your wellness benefit, complete the form by following the instructions. Please check tm your policy for a list of covered wellness procedures or call 180099 aflac 18009923522 for a wellness form specifically tailored for your policy. Hospital indemnity plan wellness benefit claim form do not write on form except as instructed. Aflac is not licensed to solicit business in new york, guam, puerto rico, or the virgin islands. Aflac also provides pap smear and mammogram benefits once per year.
Please fully complete the claim form for the wellness benefit. Please check this box if you are filing for a wellness benefit under multiple coverages. Aflac claims appeals, po box 84065, columbus, ga 319089998 please use the claim appeal form to organize your request. If you are interested in filing your claim online, register using smartclaim. Request for cancellation of policycertificate aflac login. Aflac herein means american family life assurance company of columbus. Please date and sign all required forms where indicated. The way to complete the online aflac claim forms on the internet. Mark only wellness exam boxes for tests andor treatments received. Simply select file online below and follow the instructions. When you use aflac smartclaim to submit accident, cancer, hospitalization or illness claims online youll get paid fast. Please check your policy for a list of covered wellness procedures or call 180099 aflac 18009923522 for a wellness form specifically tailored for your policy. I am able to modify the forms to fit my special needs and requirements.
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