Fillable Aflac Ltc Hhc Claim Form V8 16

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Aflac Ltc Hhc Claim Form V8 16

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The Aflac Ltc Hhc Claim Form V8 16 form is 6 pages long and contains:

  • 4 signatures
  • 40 check-boxes
  • 97 other fields

Country of origin: US
File type: PDF

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For Claims Customer Service: Phone: (800) 225-3859
For Claims Submission: Fax: (508) 853-0310 Email: Claims@ULAflac.com
Mail: Attn: Life Claims PO Box 60676, Worcester, MA 01606
Aflac V8.16
Long Term Care / Home Health Care Claim
Instructions: In order to provide prompt service to your request for Long Term Care, Home Health Care, and/or Adult Care Benefits,
complete form as follows:
• Section A – Statement of the Insured in its entirety
• Sign and Date the Disclosure Authorization
• Attending Physician’s Statement to be completed by your physician
Section A – Statement of the Insured Policy / Certificate #: _________________
Name: ______________________________________ DOB: ____/____/____ SSN: _______________________
Address: _____________________________________________________________________________________________
Street City State Zip Code
Phone #________________________ Home Cell Work E-Mail Address: ___________________________________________
Employer: _____________________________________________________________________________________________
Name Address Phone
Date Last Worked: ____/____/____
Benefit(s) applied for:
Long Term Care Home Health Care Adult Day Care Assisted Living
Name & Address of Agency Providing Care: _______________________________________________________________________
Name Address Date of Service
Physician Who Is Certifying Care: _______________________________________________________________________________
Name Address Date of Service
Doctors Consulted Other Than Certifying Physician, For Present Condition:
__________________________________________________________________________________________________________
Name Address Phone Dates
Name of Hospital: _____________________________________ Date Admitted: ____/____/____ Date Discharged: ____/____/____
Date of Accident/ Illness: ____/____/____ Description of Accident / Illness: ______________________________________________
Is this a work-related injury or illness?
Yes No Place of Accident: ________________________________________________
Nature & Extent of Injury or Illness: _________________________________________________ Date of 1
st
Treatment: ___/___/___
Have you had any other medical attention in the past five (5) years?
Yes No
If yes, please complete following:
_______________________________________________________________________________________________
Doctor’s Name Address Phone
_______________________________________________________________________________________________
Diagnosis Dates of Treatment
What activities of Daily Living are you currently unable to perform without assistance? (Please check all that apply)
Bathing Toileting Dressing Walking Eating Taking Medication Getting In & Out of Bed
If any checked above, please explain: ____________________________________________________________________________
If patient / insured is incompetent, please provide name, address, and notarized papers for Guardian, Conservator, Power of Attorney,
or Trustee who is responsible for financial affairs.
Name: _______________________________________________________________________________________________
Address: _____________________________________________________________________________________________
Street City State Zip Code
*** Complete & Sign Disclosure Authorization Portion of Claim Form ***
For Claims Customer Service: Phone: (800) 225-3859
For Claims Submission: Fax: (508) 853-0310 Email: Claims@ULAflac.com
Mail: Attn: Life Claims PO Box 60676, Worcester, MA 01606
Aflac V8.16
Long Term Care / Home Health Care Claim
Section B – Attending Physician’s Statement (To be completed by the Attending Physician)
Your prompt completion of all items on this form will help us help your patient
Name of Patient: ____________________________________ Age: ________________________
Date of illness (1
st
Symptom) or injury (accident): ____/____/____ Date 1
st
consulted you for this condition: ____/____/____
If patient has had same or similar illness or injury, list dates & diagnosis: _________________________________________________
Name & Address of Referring Physician or Other Sources (Public Health Agency):
__________________________________________________________________________________________________________
Name Street City State Zip Code
Has patient any chronic or constitutional disease, physical defect, or deformity? Yes No
If yes, describe:___________________________________________________________________________________________
Patient’s Diagnosis & ICD-Code: ______________________________________________________________________________
The patient needs assistance with the following (please check all that apply):
Bathing
Toileting
Dressing
Walking
Eating
Taking Medication
Getting In & Out of Bed
Cognitive Impairment:
Yes
No
Does patient suffer from any mental, psychoneurotic or personality disorder without demonstrable organic disease? Yes No
If yes, describe:___________________________________________________________________________________________
Type of Service Receiving
Receiving
This
Service?
Type of Agency/
Facility
Name & Address of Agency / Facility
Phone #
License #
Yes
Home/Health Care
Yes
Adult Care Center
Yes
Long Term Care
Yes
Assisted Living
If yes to either Long Term Care or Assisted Living, please provide the following:
Licensed By State? Yes No
License #:
Licensed as what?
(Please check)
Skilled Nursing Care Intermediate Nursing Care Residential
Other (Please specify):
What is your prognosis for recovery and/or cessation of treatment? ______________________________________________________
Expected length of confinement or service? From: ____/____/____ To: ____/____/____
Physician’s name (please print)_____________________________________________ Specialty_____________________________
Phone: _____-_____-_______ Fax: _____-______-_____
Address: _____________________________________________________________________________________________
Street City State Zip Code
Signature___________________________________________ Date ____/____/____
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signature
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For Claims Customer Service: Phone: (800) 225-3859
For Claims Submission: Fax: (508) 853-0310 Email: Claims@ULAflac.com
Mail: Attn: Life Claims PO Box 60676, Worcester, MA 01606
Aflac V8.16
Long Term Care / Home Health Care Claim
State Required Fraud Warnings
Fraud Statement for Alaska and New Hampshire Residents: A person who knowingly and with intent to injure, defraud or deceive an insurance
company, files a claim containing false, incomplete or misleading information may be prosecuted under state law.
Fraud Statement for AZ Residents: For your protection Arizona law requires the following statement to appear on this
form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil
penalties.
Fraud Statement for CA Residents: For your protection, California law requires the following to appear: Any person who knowingly presents a
false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Fraud Statement for CO Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company
for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages.
Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable
from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Fraud Statement for FL Residents: 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, incomplete or misleading information is guilty of a felony of the third degree.
Fraud Statement for Kansas, and Oregon Residents: Any person who knowingly, and with the intent to injure, defraud, or deceive an insurance
company, files a statement of claim containing any false, incomplete, or misleading information may be guilty of insurance fraud, which may be a crime.
Fraud Statement for KY Residents: A person who knowingly and with intent to defraud any insurance company or other person files a 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.
Fraud Statement for Arkansas, Louisiana, New Mexico, Texas, and West Virginia Residents: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
Fraud Statement for Maryland Residents: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit
or knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.
Fraud Statement for MN Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
FRAUD STATEMENT FOR PENNSYLVANIA RESIDENTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON FILES ANY 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.
Fraud Statement for New Jersey: ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING
INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
Fraud Statement for Ohio Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
FRAUD STATEMENT FOR DISTRICT OF COLUMBIA, MAINE, TENNESSEE, VIRGINIA AND WASHINGTON RESIDENTS: IT IS A CRIME TO
KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF
DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.
Fraud Warning for Delaware, Idaho, Indiana, and Oklahoma, As Well as for the Residents of All States Not
Specifically Listed WARNING: Any person who knowingly, and with the intent to injure, defraud, or deceive an insurance
company, files a statement of claim containing any false, incomplete, or misleading information may be guilty of insurance
fraud, which is a felony.
For Claims Customer Service: Phone: (800) 225-3859
For Claims Submission: Fax: (508) 853-0310 Email: Claims@ULAflac.com
Mail: Attn: Life Claims PO Box 60676, Worcester, MA 01606
Aflac V8.16
Long Term Care / Home Health Care Claim
DISCLOSURE AUTHORIZATION Insured’s Name (Please print): _______________________________
I AUTHORIZE any doctor, hospital, clinic, other medical facility or provider of health care, insurer or reinsurer,
consumer reporting agency, insurance support organization, insurance agent, employer, financial institution, the Social
Security Administration, the Internal Revenue Service, the Veterans Administration or any other organization or
person having any knowledge of me or my health to give to Trustmark Insurance Company and affiliates or its employee
and agents, or any other consumer reporting agency any information as to cause, treatment, diagnoses, prognoses,
consultations, examinations, tests or prescriptions with respect to my physical or mental condition or information
concerning me, my occupation, employment history, earnings or finances or information otherwise needed to determine
policy claim benefits due me. This may include, but is not limited to, HIV Infection, any disorder of the immune system
including Acquired Immune Deficiency Syndrome (AIDS), driving records, mental illness, or use of alcohol or drugs
I further AUTHORIZE the Social Security Adm. to release information or records about me to Trustmark Insurance
Company or authorized representatives. This information is to be released in order to properly adjudicate my claim or
continue my eligibility for benefits. Please release detailed earnings for up to the last ten years and/or summary
record of total earnings and/or information from master benefit records regarding award, denial or continuing benefits.
This authorization may be revoked by me. Any such revocation must be in writing, must be signed and dated by me and
must be forwarded directly to the Trustmark Insurance Company. I AGREE the information obtained with this
Authorization may be used by Trustmark Insurance Company and affiliates to determine policy claim benefits with
respect to the Insured. A photocopy of this authorization is as valid as the original and I may request a copy. This
authorization will be in force for the term of coverage of the policy up to 12 months from the date shown below. I
understand that if I revoke or fail to sign this authorization or alter its content it may affect the handling of my claim
including denial of benefits under my policy.
I understand that there is a possibility of redisclosure of any information disclosed pursuant to this authorization and
that information, once disclosed, may no longer be protected by federal rules governing privacy and confidentiality
I AUTHORIZE Trustmark Insurance Company and affiliates to report to ICS, any dates of past or present claims filed by
me
Residents of MT – You are entitled to request a record of any subsequent disclosure of information.
RESIDENTS OF NM – Revocation of the authorization must be made within 10 days after its receipt by
Trustmark Insurance Company; this applies only to confidential abuse information.
Residents of Florida – Any person who knowing and with intent to injure, defraud or deceive any insurance
company files a statement of claim or application containing any false, incomplete or misleading information is
guilty of a felony of the third degree.
Residents of NY – 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the
stated value of the claim or each such violation.
Date: ___/___/___ Signature: ___________________________________________________________
Date of Birth: ___/___/___ Relationship, if other than insured: ________________________________________
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For Claims Customer Service: Phone: (800) 225-3859
For Claims Submission: Fax: (508) 853-0310 Email: Claims@ULAflac.com
Mail: Attn: Life Claims PO Box 60676, Worcester, MA 01606
Aflac V8.16
Long Term Care / Home Health Care Claim
Insured Statement of Claim – Communication
1. CONSENT FOR USE OF ELECTRONIC COMMUNICATIONS (EMAIL, SMS/MMS TEXT MESSAGING)
To ensure the best and fastest communication, we would like to communicate with you using either email or text
messaging. Please complete this section if we can communicate with you electronically, concerning your claim, benefits,
policy, premium or condition.
May we communicate with you electronically?
No
Yes, by Text Messages - Please provide cell phone #: (_____) - ______ - ______
Yes, by Email Please provide email address: ________________________________________@ _______________
If you chose to communicate with us electronically, you should be aware that electronic communication is not secure
unless it is encrypted. We strongly encourage you to use encrypted communication when sending sensitive and/or
confidential information. By sending sensitive or confidential electronic messages that are not encrypted, you accept the
risks of such lack of security and possible lack of confidentiality. If you elect to communicate from your workplace
computer, you should also be aware that your employer and its agents, have access to electronic communication
between you and us.
I understand that by selecting text messaging, regular text messaging rates may apply for any texts I receive from
Trustmark and I assume responsibility for any costs associated with these text messages. This consent shall remain in
effect unless revoked in writing.
To ensure a smooth email experience, please be sure that your computer has the most up to date version of Adobe
Reader. You should add our email address to your address book contact list and add us to your email server or spam
filter approved listing. If you don’t see email from us in your email inbox, be sure to check your spam, clutter, junk or
bulk email folder. You can choose to stop electronic communication at any time by revoking this authorization. If you no
longer wish to communicate via electronic means we will correspond with you via US mail. If you require copies of any
communication sent to you by email/text in paper form, please contact us. There is no cost to you to obtain copies of
electronic communication in paper format.
Authorization
I may revoke or update this authorization in writing at any time or by email to
Claims@ULAflac.com.
Trustmark Insurance may rely on the information I provide for the adjudication of my claim as a result of this
authorization until receipt of my revocation notice. This authorization is valid for two (2) years. I may request a copy of
this authorization and a copy is as valid as the original.
Policy Owner Signature Date
Printed Name Social Security Number
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signature
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For Claims Customer Service: Phone: (800) 225-3859
For Claims Submission: Fax: (508) 853-0310 Email: Claims@ULAflac.com
Mail: Attn: Life Claims PO Box 60676, Worcester, MA 01606
Aflac V8.16
Long Term Care / Home Health Care Claim
Insured Statement of Claim – Communication (Continued)
2. Third Party Communication Authorization
Please complete this authorization if you would like us to discuss, to release, or to provide information to a family
member, friend, or other third party such as your agent or employer.
My Spouse or Partner: (Name) _______________________________________________________________________
☐ All Information (All policy and claim information)
☐ All Information except Medical Information (diagnosis, medical condition, reason for claim, treatment, physicians)
My Family Member: (Name and Relationship)
_____________________________________________________________
☐ All Information (All policy and claim information)
☐ All Information except Medical Information (diagnosis, medical condition, reason for claim, treatment, physicians)
Other Third Party: My Agent: Yes ☐ My Employer: Yes ☐
Or Name a Specific Third Party (Name and Relationship) ___________________________________________________
☐ All Information (All policy and claim information)
☐ All Information except Medical Information (diagnosis, medical condition, reason for claim, treatment, physicians)
I agree that if I authorize release of all claim information this may include health information which may be related to
disorders of the immune system including but not limited to HIV and AIDS, use of alcohol or drugs, mental and physical
condition, history, or treatment.
I understand that any information shared may be subject to re-disclosure and might not be protected by certain federal
regulations governing the privacy of health information relative to my condition.
Authorization
I may revoke or update this authorization in writing at any time or by email to
Claims@ULAflac.com.
Trustmark Insurance may rely on the information I provide for the adjudication of my claim as a result of this
authorization until receipt of my revocation notice. This authorization is valid for two (2) years. I may request a copy of
this authorization and a copy is as valid as the original.
Policy Owner (Or Policy Owner’s Personal Representative’s Signature Date
- -
Printed Name Social Security Number
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Aflac Ltc Hhc Claim Form V8 16

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Completed 2 July 2020

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