Get American Fidelity Physician Expense Filed Form

Completing the American Fidelity Physician Expense Filed Form online can streamline the process of filing a claim for medical expenses resulting from injury or sickness. This guide will provide you with clear, step-by-step instructions to assist you in filling out the form accurately.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to access the form and open it in the online editor.
2. Fill in the name of the insured (policyholder) at the designated section, along with the date of birth and the AFA account number. Ensure that these details are accurate to avoid processing delays.
3. Complete the residence address fields, including the street, town, state, and zip code. This is essential for correspondence regarding your claim.
4. Provide a mailing address if it differs from your residence address. Again, fill out all necessary information, including street, town, state, and zip code.
5. Enter the name of your employer along with their address. Include the city, state, and zip code. Completing this information is necessary for verification of employment.
6. Next, specify your contact numbers—both home and work phone numbers—and your occupation. This information helps facilitate communication regarding your claim.
7. In the section for authorization to use or disclose protected health information, review the statement provided and sign it. This authorizes the necessary parties to access your medical records for processing your claim.
8. Indicate the date when the accident or illness began, and describe the nature of the illness or accident as comprehensively as possible.
9. Answer whether the accident or illness was work related, and if it was an accident, provide detailed information on where and how it happened.
10. Document the dates of all treatments and specify any days you were unable to work a full day due to your illness or injury.
11. Confirm whether you were scheduled to work on the day of medical treatment and if you were totally disabled. Provide additional explanations if required.
12. Attach the diagnosis and itemized charges from your medical provider directly to the form. This documentation is crucial to support your claims.
13. If you desire direct deposit for benefits, complete the direct deposit authorization section and attach a voided check for processing.
14. Once all fields are complete and verified, you may save the changes to your online form. You can then download, print, or share the completed document as needed.

Begin filling out your American Fidelity Physician Expense Filed Form online today to ensure a timely processing of your claim.