Get Please Note That These Benefits Are Not Payable For Treatment Within The First 12 Months Of The

Filling out the Accident Wellness Benefit Claim Form can be straightforward with the right guidance. This guide will walk you through each section of the form to ensure a smooth submission process.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the Policyholder Information section. Provide the middle initial, first name, last name, birth date, and policy number of the policyholder. Ensure that you enter all details accurately.
3. Next, complete the Patient Information section by indicating the patient's middle initial, first name, last name, birth date, sex, and relationship to the policyholder. Be sure to select the appropriate relationship.
4. For the Wellness Exam section, mark all applicable wellness exams that have been performed by checking the corresponding boxes. Include treatment dates for all exams listed.
5. If relevant, provide the dates of the Pap smear and mammogram if you have received those services. This information is essential for your claim.
6. Fill out the Physician Information by providing the name, phone number, street address, city, state, and ZIP code of the physician who conducted the wellness exams.
7. Before finalizing, ensure you review the completed form for accuracy. Sign and date the form as the policyholder to certify that the information provided is true and correct.
8. After ensuring all information is accurate, save the form, and print it if necessary. You can then mail the completed form to the Aflac claims department address specified at the bottom of the form.

Complete your Accident Wellness Benefit Claim Form online today to ensure no delays in processing your claim.