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Get Aflac Wellness Claim Form

DUCK Cancer Screening Wellness Benefit Claim Form Please read all instructions. Failure to follow these instructions will delay the processing of your claim. Do not include receipts statements or other documentation with this form. Your Aflac policy provides one Wellness Benefit per covered person per calendar year and this form is designed specifically for this benefit. Please check your policy for a list of covered wellness procedures or call 1-800-99-AFLAC 1-800-992-3522 for a Wellness Form specifically tailored for your policy. Claims for all other benefits covered under your Cancer policy must be filed separately using the Cancer Claim Form. If any of your wellness tests resulted in a diagnosis of cancer please submit your claim for cancer treatment separately using the Cancer Claim Form. If your Aflac policy also provides one Mammogram Benefit per calendar year please mark the appropriate box and indicate the date the mammogram was performed. Please check your policy for specific benefits covered under your policy. To receive your Wellness Benefit complete the form by following the instructions provided. Please print a separate form for each additional covered family member or call 1-800-99-AFLAC 1-800-992-3522 to request additional forms. Sign date and mail the completed form to the Aflac address shown below. Policyholder Information Middle Initial Policyholder s First Name M D Y ZIP of mailing address Birth Date Policy Number Patient Information First Name Relationship Last Name Sex Primary Dependent Child Spouse Male Female Patient s Wellness Exam Flexible sigmoidoscopy Treatment Date Thermography Colonoscopy Hemocult stool specimen Chest X-ray Virtual colonoscopy CEA blood test for colon cancer Pap smear - ThinPrep CA 125 blood test for ovarian cancer Breast ultrasound/Breast sonogram Pap smear Biopsy Mammogram Provide Actual Cost for Mammogram Physician Information Phone Number - Name Street Address City State ZIP 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. Do not write on the form except as instructed. Incomplete forms cannot be processed and will be returned. Please do not fax this completed form to Aflac. Mark only wellness exam box es for test s that you had performed. POLICYHOLDER NAME POLICYHOLDER STREET ADDRESS CITY STATE ZIP BIRTHDATE American Family Life Assurance Company of Columbus Aflac Attn Claims Department 1932 Wynnton Road Columbus GA 31999-7251 1-800-99-AFLAC 1-800-992-3522 aflac.com 1-800-SI-AFLAC 1-800-742-3522 en espan l Z06197CA GA Some of the tests listed may not be covered under the Wellness Benefit of your policy. date the Pap smear was performed* Please check your policy for specific benefits covered under your policy..

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