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Cancer Screening Wellness Benefit Claim Form


Cancer Screening Wellness Benefit Claim Form
Cancer Screening Wellness Benefit Claim Form
Do not include receipts, statements, or other documentation with this form.
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.
Cancer Screening Wellness Ben efit Claim Form
POLICYHOLDER NAME:
POLICYHOLDER STREET ADDRESS:
CITY, STATE, ZIP:
BIRTHDATE:
Your Aflac N ew York policy pro vi des one We llness Benefit per covered person, p er calendar year, and this form is designe d
specifically for this benefit. To receive your W ellness Benefit, complete the form by following the instructions provided.
Please print a separa te fo rm for each additio nal covered family me mber or call (1-800-366-3436) to request additional
forms. Claims fo r a ll othe r benefits covered under your Cancer po licy m ust be filed separate ly, using the Ca nce r Claim
Form.
If any of y our wellness tests resulted in a diagnosis of cancer, please submit your claim for cancer treatment separately,
using the Ca ncer Cla im Fo rm.
If your Aflac New York policy a lso provides one Mammogram Benefit per calendar year, please mark the appropriate box and
indica te the d ate the mammogram was performed. Please check your policy for spe cific benefits covered unde r your policy .
If your Aflac New York policy also provides one Pap Smear Benefit per calendar year, please mark the appropriate box and
indica te th e d ate the Pap smear wa s perfo rmed. Please check your policy fo r specific benefits co vered unde r y our policy .
DUCK
Please read all instructions.
Failure to follow these instructions will delay the processing of your claim.
American Family Life Assurance Company of New York (Aflac New York)
Attn: Claims Department 1932 Wynnton Road Columbus, GA 31999-7251
(1-800-366-3436) aflacny.com
NYZ06197CA NY
Cancer Screening Wellness Benefit Claim Form
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