Fillable Aflacny Convalescent Care Benefit Claim Form V8 16

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Aflacny Convalescent Care Benefit Claim Form V8 16

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The Aflacny Convalescent Care Benefit Claim Form V8 16 form is 5 pages long and contains:

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  • 59 check-boxes
  • 92 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
Trustmark Life Insurance Company of New York, Albany, NY Aflac V8.16
Administrative Office: PO Box 60676, Worcester, MA 01606
Convalescent Care Benefit Claim NY
Instructions: In order to provide prompt service to your request for benefits under the Convalescent Care Benefit Rider, complete
form as follows:
• Section A – Statement of the Insured in its entirety
• Sign and Date the Disclosure Authorization
• Have your physician complete the Attending Physician’s Statement
Completed claim form should be returned to: Trustmark Life Insurance Company of New York, PO Box 60676, Worcester, MA 01606
Benefit payments may only be made if the payments are subject to favorable tax treatment by the Federal Government. When
determining whether the benefit payments will receive favorable tax treatment, the payment of benefits from all insurance policies must
be considered.
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/Supervisor: __________________________________________________________________________________________
Name Address Phone
Date Last Worked: ____/____/____
Benefit(s) applied for:
Long Term Care Facility Benefit Assisted Living Benefit Home Health Benefit
Adult Day Care Benefit
Are you covered by other insurance policies that pay similar benefits?
Yes No
If yes, is policy tax-qualified?
Yes No
Name & Address of Carrier: ____________________________________________________________________________________
Name Address
Benefit Amount: ________________________
Per Day Per Month
Licensed Health Care Providers 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: ____________________________________________________________________________________
Name Address
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
Trustmark Life Insurance Company of New York, Albany, NY Aflac V8.16
Administrative Office: PO Box 60676, Worcester, MA 01606
Convalescent Care Benefit Claim NY
Section A – Statement of the Insured (Continued)
Complete for Home Health Care or Adult Day Care Only:
Name & Address of Agency Providing Home Health Care:
__________________________________________________________________________________________________________
Name Address Date of Service
Physician Who Is Certifying Care:
_________________________________________________________________________________________________________
Name Address Date of Service
Complete for all types of care or benefits:
AUTHORIZATION — I HEREBY AUTHORIZE ANY LICENSED PHYSICIAN, MEDICAL PRACTITIONER, HOSPITAL,
CLINIC, OR OTHER MEDICAL OR MEDICALLY RELATED FACILITY, OR OTHER ORGANIZATIONS, INSTITUTION OR
PERSON WHICH MAY HAVE INFORMATION PERTINENT TO MY CLAIM, INSURANCE COMPANY OR CONSUMER
REPORTING AGENCY, OR EMPLOYER HAVING ANY RECORDS OR INFORMATION PERTAINING TO ALL MEDICAL
HISTORY, MENTAL OR PHYSICAL CONDITION, EVALUATION, DIAGNOSIS, TREATMENT OR PROGNOSIS,
SPECIFICALLY TO INCLUDE PSYCHIATRIC, COMMUNICABLE OR INFECTIOUS DISEASES, INCLUDING AIDS AND
ANY OTHER NON-MEDICAL INFORMATION OF ME TO GIVE TO TRUSTMARK LIFE INSURANCE COMPANY OF NEW
YORK OR ITS LEGAL REPRESENTATIVES, ANY AND ALL SUCH INFORMATION. I FURTHER ACKNOWLEDGE THAT
THE INFORMATION OBTAINED BY USE OF THIS AUTHORIZATION WILL BE USED BY TRUSTMARK LIFE
INSURANCE COMPANY OF NEW YORK TO DETERMINE MY ELIGIBILITY FOR BENEFITS. I UNDERSTAND THAT I
MAY REQUEST A COPY OF THIS AUTHORIZATION. I FURTHER AGREE THAT A PHOTOSTATIC COPY OF THIS
AUTHORIZATION SHALL BE AS VALID AS THE ORIGINAL, AND THAT SUCH AUTHORIZATION SHALL BE VALID FOR
ONE YEAR FROM THE DATE SHOWN BELOW.
By signing this claim form you declare that your application for this benefit is voluntary and without coercion on the part of
any third party.
No health care facility as defined in section 20 of the Public Health Law can require any person to accelerate payment of a
death benefit as a condition of admission to such health care facility or for providing any care in such facility.
Any 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, and shall also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such
violation.
Insured Signature______________________________________________________________________ Date ____/____/____
Date of Birth: ___/___/___ Relationship, if other than insured: ________________________________________
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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
Trustmark Life Insurance Company of New York, Albany, NY Aflac V8.16
Administrative Office: PO Box 60676, Worcester, MA 01606
Convalescent Care Benefit Claim NY
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 Good Fair Poor
Short Term Memory
Long Term Memory
Understands & Follows Simple Directions
Orientation To:
Time
Place
Person
Does patient suffer from any mental, psychoneurotic or personality disorder without demonstrable organic disease? Yes No
If yes, describe:___________________________________________________________________________________________
Type of Service Receiving
Receiving
Type of Agency/
Facility
Name & Address of Agency / Facility
Yes
Home/Health Care
Yes
Adult Care Center
Yes
Long Term Care
If yes to either Long Term Care, please provide the following:
Tax ID of Facility:
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)_____________________________________________ Phone: _____-_____-_______
Address: _____________________________________________________________________________________________
Street City State Zip Code
I certify that the above Confinement, Care, or Service is medically necessary.
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
Trustmark Life Insurance Company of New York, Albany, NY Aflac V8.16
Administrative Office: PO Box 60676, Worcester, MA 01606
Convalescent Care Benefit Claim NY
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 Life Insurance Company of New York 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 Life Insurance Company of New York 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
Trustmark Life Insurance Company of New York, Albany, NY Aflac V8.16
Administrative Office: PO Box 60676, Worcester, MA 01606
Convalescent Care Benefit Claim NY
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 Life Insurance Company of New York 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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signature
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Aflacny Convalescent Care Benefit Claim Form V8 16

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Completed 2 July 2020

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