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Accident Wellness Benefit Claim Form

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Accident Wellness Benefit Claim Form Page 2
Accident Wellness Benefit Claim Form
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Annual physical
Ultrasound
PSA (blood te st for prosta te ca ncer)
Pap smear
Bloo d screening
Immunizations
Eye exam
Physician Information
Mammogram
Patient Information
Wellness Exam
Treatment
Date:
Pap Smear
Date:
Phone Number:
Treatm en t date m ust be provided.
First Name:
Middle
Initial:
Last Name:
Rel a tionship: Se x:
Primary
Po licyholder
Spouse
Dependent
Child
Male Female
Pa tient
Birth Date:
MMDDYYYY
MMDDYYYY
MMDDYYYY MMDDYYYY
Name:
Street Addr es s :
State: ZIP:City:
Policyholder Information
Po licyholder First Name: Po licyholder Last Name:
Po licyholder
Birth Date:
MMDDYYYY
Policy Number
I certify that the information provided is true and correct:
_________________________ __________
POLICYHOLDER SIGNATURE DATE
ACCIDENT WELLNESS BENEFIT CLAIM FORM
Flex ible sigmoidoscopy
Dental e x am
DUCK
Ma m m ogram
Date:
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomple te, or misleading information is guilty of a felony of the third degree.
Some of the tests listed may not be covered under the Wellness Benefit of your policy. 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.
Please use black or blue ink only and print legibly when completing this form in its entirety. Keep a
copy of the supporting documentation and this completed form for your records. Sign, date, and
mail the completed form to the A flac address shown below.
Middle
Initial:
ZIP of mailing address:
Z06197AD FL
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 español
DUCK
Accident Wellness Benefit Claim Form
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