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All documents. Failure to complete this form in its entirety may result in a delay in processing this claim. INSTRUCTIONS: Complete Section A: Policyholder/Patient Information and sign your claim form. Have the treating physician complete Section B: Physician's Statement and sign the claim form. If you are filing for disability, please complete the Initial Disability Claim Form (NY-S00224) as well. Forms are available on our web site at aflacny.com. Submit all bills related to this claim, such.
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Requestor FAQ
UB04 (itemized hospital bill). ER report or operative report. (Please obtain the supporting documents for the corresponding benefit.)
✓ Email form to groupclaimfiling@aflac.com or fax to 1.866. 849.2970. Please review your policy for specific benefits covered under your plan. To prevent processing delays, please have claim form completed in full and return the signed HIPAA.
A hospital indemnity claim requires supporting documentation for review of benefits, itemized bills showing medical treatment dates and diagnosed conditions, hospital admission and discharge papers for inpatient hospital admission and confinement benefits, pharmacy receipts for prescription drug reimbursement, and a ...
Itemized hospital bill (IHB). UB04 (itemized hospital bill). ER visit. (Please obtain the supporting documents for the corresponding benefit.)
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