Fillable Cancer Claimform Group Cancer Claims (Aflac Insurance)

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Cancer Claimform Group Cancer Claims (Aflac Insurance)

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The Cancer Claimform Group Cancer Claims (Aflac Insurance) form is 6 pages long and contains:

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  • 34 check-boxes
  • 135 other fields

Country of origin: US
File type: PDF

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Post Office Box 84075 * Columbus, GA. 31993
Phone (800) 433-3036 * Fax (866) 849-2970
groupclaimfiling@aflac.com
CANCER CLAIM FORM INSTRUCTIONS
To avoid delays in processing of your claim form, complete each section attaching documentation below
when it applies.
Supporting Documentation Needed
Itemized bill if there was a hospital stay (UB04 from the hospital or medical facility)
Chart Note to include admission and discharge paperwork if there was a hospital stay
Copy of the operative report or surgeon’s bill to include charges, if surgery was performed
Itemized bill from physician’s office (HCFA 1500 from treating physician’s office)
Pathology report or exam with diagnosis, if this is the first claim.
Itemized bill for chemotherapy or radiation, if services were provided.
If filing for the Lump Sum Cancer Plan, submit a copy of the patient’s birth certificate.
Benefit Assignment-Benefits are payable to the policy holder unless written authorization is
received from you or your healthcare provider to assign benefits to the provider. If you choose to
assign benefits, attach a signed and written request.
Email form to groupclaimfiling@aflac.com or fax to 1.866.849.2970.
Post Office Box 84075 * Columbus, GA. 31993
Phone (800) 433-3036 * Fax (866) 849-2970
groupclaimfiling@aflac.com
CANCER CLAIM FORM
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.
Submit medical documentation from your healthcare provider to support your claim.
Benefits are payable to you unless we receive written authorization from your provider to assign benefits to them or from
you to pay your benefits elsewhere. This is called an assignment. If you wish to assign your benefits, please send a written
request.
AUTHORIZATION
Several states require that the following statement appear on the claim forms:
Any person, who knowingly and with intent to defraud any insurance company, files a statement of claim containing any
materially false, incomplete or misleading information, is guilty of a crime.
I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my
knowledge and belief. I have read the fraud notice included with this form.
Policyholder’s Signature: _________________________________________________ Date: _____________________
Patient’s Signature: _____________________________________________________ Date: _____________________
POLICYHOLDER/PATIENT INFORMATION
EMPLOYER’S NAME
POLICYHOLDER’S EMAIL ADDRESS
POLICY HOLDER’S NAME
POLICY NO.
SOCIAL SECURITY NO.
DATE OF BIRTH
POLICYHOLDER’S ADDRESS CITY STATE ZIP CODE
☐
CHECK BOX IF THIS IS A PERMANENT ADDRESS CHANGE
POLICYHOLDER’S TELEPHONE NO.
PATIENT’S NAME
RELATIONSHIP TO T HE
POLICYHOLDER
PATIENT’S DATE OF BIRTH
PATIENT’S DATE OF DEATH
(IF APPLICABLE)
WHAT DATE WAS THE CANCER FIRST DIAGNOSED BY A PATHOLOGIST?
(ATTACH A COPY OF THE PATHOLOGY REPORT)
HAVE YOU EVER HAD THE SAME OR A SIMILAR CONDITION?
YES NO
NAME, ADDRESS AND TELEPHONE NUMBER FOR ALL ATTENDING PHYSICIANS FOR THE CANCER
(ATTACH A SEPARATE LIST IF ADDITIONAL SPACE IS NEEDED)
NAME
ADDRESS
TELEPHONE NO
IF THE CANCER REQUIRED HOSPITALIZATION, PROVIDE THE NAME AND ADDRESS OF THE TREATING FACILITY
(ATTACHED A SEPARATE LIST IF ADDITIONAL SPACE IS NEEDED)
NAME
ADDRESS
TELEPHONE NO
*By providing your e-mail address above, you consent to the use of electronic transactions in connection with your CAIC policies, contracts,
and/or accounts to the extent available and permitted by law (which may include, but not limited to: invoices, claim correspondence, contracts,
surveys, and other materials that CAIC is, or may be, legally required to deliver to you).
• Transportation/Lodging Information: To be completed if you are filing a claim for transportation or lodging: (please submit
the hotel receipts and mileage information) *For additional information, please refer to your policy language.
DATE
TO/FROM
ROUND-TRIP MILEAGE
TYPE OF TREATMENT
ATTENDING PHYSICIAN’S STATEMENT
PATIENT’S NAME
36T
DATE OF BIRTH
DATE OF DEATH (IF APPLICABLE)
WHEN DID SIGNS AND/OR
SYMPTONS FIRST APPEAR?
HAS THE PATIENT EVER RECEIVED MEDICAL ADVICE OR TREATMENT
FOR THIS OR A SIMILAR CONDITION?
☐YES, WHEN ☐ NO
DIAGNOSIS (INCLUDING COMPLICATIONS)
Has the patient been diagnosed with cancer? ☐No ☐Yes (If yes, submit the initial pathology report or exam with
diagnosis)
Type of cancer Date of initial diagnosis
First date of treatment for this diagnosis
NAME, ADDRESS AND PHONE NUMBER OF PATIENT’S PRIMARY TREATING PHYSICIAN
Was the patient treated by any other physicians?
☐
No
☐
Yes (If yes, provide physician name (s), address, phone
number):
Physician Name
Address
Phone
Admission Date
Discharge Date
Hospital Name, Address, City, State, Zip Code
Did the patient undergo surgery for this condition?
☐
No
☐
Yes (If yes, submit a copy of the operative report or
surgeon’s bill to include charges.)
Surgical Center
Outpatient Hospital Inpatient Hospital
Where was the surgery performed?
Facility Name, Address, City, State, Zip Code
Has the patient received chemotherapy?
☐
No
☐
Yes (If yes, submit a copy of itemized billing.)
Name of facility where chemotherapy was received, Address, City, State, Zip Code
Has the patient received oral chemotherapy? ☐No ☐Yes (If yes, submit pharmaceutical statements.)
Has the patient received topical chemotherapy (Treatment with anticancer drugs in a lotion or cream applied to the skin)?
☐
No
☐
Yes (If yes, submit pharmaceutical statements.)
Has the patient received radiation therapy?
☐
No
☐
Yes (If yes, submit a copy of itemized billing.)
Name of facility where radiation was received, Address, City, State, Zip Code
ATTENDING PHYSICIAN’S SIGNATURE
I hereby certify that the above described information is based upon reasonable medical probability, and is true to the best of my knowledge and belief.
NAME (ATTENDING PHYSICIAN) PLEASE PRINT
DEGREE
TELEPHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
SIGNATURE
DATE
MEDICAL ID#
Office
AUTHORIZATION TO OBTAIN INFORMATION
Primary Certificate Holder Name:
SSN(optional):
Date of Birth:
Certificate Number(s):
Address:
City:
State:
Zip:
Name of Individual Subject to Disclosure (If not the primary Certificate Holder):
Date of Birth:
Relationship to Primary Certificate Holder:
Self
Spouse Domestic Partner Child Stepchild Grandchild
I.
Authorization:
For the purpose of evaluating my eligibility for insurance and for benefits under an existing certificate, including checking
for and resolving any issues that may arise regarding
incomplete or incorrect information on my application for coverage
and/or claim form, I hereby authorize the disclosure of the following information(defined below) about me
and, if
applicable, my dependents, from the sources listed below to Continental American Insurance Company (CAIC), or any
person or entity acting on its part, to include
American Family Life Assurance Company of Columbus and American
Family Life Assurance Company of New York (collectively, “Aflac).
II.
Disclosure of Health Information:
Health information may be disclosed by any health care provider, health plan (including CAIC or Aflac, with respect to other
CAIC or Aflac coverages) or health care clearinghouse that
has any records or knowledge about me. Health care provider
includes, but is not limited to, any licensed physician, medical or nurse practitioner, nurse, pharmacist, osteopath,
psychologist, physical or occupational therapist, chiropractor, dentist, audiologist or speech pathologist, podiatrist, hospital,
medical clinic or laboratory, pharmacy, rehabilitation
facility, nursing home or extended care facility, prescription drug
database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may
also be
disclosed by any insurance company or the Medical Information Bureau (MIB). Health information includes my entire
medical record, but does not include psychotherapy
notes. Some information obtained may not be protected by certain
federal regulations governing the privacy of health information, but the information is protected by state privacy
laws and
other applicable laws. CAIC will not disclose the information unless permitted or required by those laws.
III.
Rights and Expiration:
I understand that I may revoke this authorization at any time, except to the extent that CAIC or Aflac has taken action in
reliance on this authorization. If I revoke this
authorization, CAIC may not be able to evaluate my application for coverage
and/or claim. To revoke this authorization, I must provide a written and signed revocation to CAIC at
the address or fax
number above. Unless otherwise revoked, this authorization shall remain in effect for two (2) years from the date signed
or upon my death, whichever occurs
first. I agree that a copy of this authorization is as valid as the original and that I or an
authorized representative may request a copy of this authorization.
IV.
Notice:
I understand that CAIC is not conditioning payment, enrollment, or eligibility for benefits on whether I sign this
authorization. I understand that if the information disclosed is protected health
information relating to a health plan and the
person or entity receiving the information is a not a health care provider or health plan covered by federal privacy
regulations, the information
disclosed may be re-disclosed by such person or entity and will likely no longer be protected
by the federal privacy regulations.
•
If records are on an adult dependent, (e.g. spouse, child over 18), the dependent must sign this form
•
If records are on a minor child the natural parent or legal guardian must sign on their behalf.
Signature of Individual Subject to Disclosure Date Signed
Legal Representative’s Printed Name Legal Representative’s Signature Legal Relationship Date
***If signed by a legal representative (e.g. Legal Guardian, Estate Administrator, Power of Attorney***
Send to:
Continental American Insurance Company
Post Office Box 84075
Columbus, GA 31993
Phone: (800) 433-3036
Fax: (866) 849-2970
Email: groupclaimfiling@aflac.com
Electronic Funds Transaction Authorization
Send to: Continental American Insurance Company
Post Office Box 84075 Phone: (800) 433-3036 Fax (866) 849-2970
Columbus, Georgia 31993
Email: groupclaimfiling@aflac.com
Authorization Agreement for Direct Deposit
I would like to: Start Stop Change direct deposit of my claim payment(s).
Account Type:
Checking Savings
**** Please provide a blank voided check or
direct deposit form from your financial
institution. Incomplete or inaccurate
information will not be processed.
9-Digit Routing Number:
Account Number:
Name of Financial Institution:
Address:
City:
State:
Zip:
Phone:
I authorize Continental American Insurance Company (CAIC) to initiate credit entries, and, if errors occur, I
authorize the correction of entries to my account as indicated. This authorization remains effective and in full force
until CAIC receives written notification from me of its termination in such time and in such manner to afford CAIC a
reasonable opportunity to act on it. Please notify CAIC immediately if your financial institution information has
changed by sending notification to the address indicated above. Should you have any questions, please contact us at
1-800-433-3036.
Policy/Certificate Holder’s Name (Print):
Address:
City/State/Zip:
Phone #:
E-mail Address:
Employer Name or Group #:
Certificate #:
***By providing your e-mail address above, you consent to the use of electronic transactions in connection with your CAIC policies, contracts, and/or
accounts to the extent available and permitted by law (which may include, but not limited to: invoices, claim correspondence, contracts, surveys, and
other materials that CAIC is, or may be, legally required to deliver to you)
Note: Forms received without signature will not be processed. Electronic signatures not accepted.
Policy/Certificate Holder Signature (Required) Date Signed:
Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. Aflac is
not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. For groups sitused in California, coverage is underwritten by Continental American Life Insurance
Company. For groups sitused in New York, coverage is underwritten by American Family Life Assurance Company of New York.
Continental American Insurance Company • 1600 Williams St • Columbia, South Carolina 29201 • 1-800-433-3036 toll-free • 1-866-849-2970 fax
FRAUD WARNING NOTICES
For use with Claim Forms
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
ALASKA:
A person who knowingly and with intent to
injury,
defraud or deceive an insurance company files a
claim
containing false, incomplete, or misleading
information may be
prosecuted under state law.
IDAHO:
Any person who knowingly, and with intent to
defraud
or deceive any insurance company, files a
statement of claim
containing any false, incomplete, or
misleading information is
guilty of a felony.
ARIZONA:
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.
INDIANA:
A person who knowingly and with intent to
defraud
an insurer files a statement of claim containing
Any false,
incomplete, or misleading information
commits a felony.
ARKANSAS:
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.
KENTUCKY:
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.
CALIFORNIA:
For your protection California law
requires the
following to appear on this form:
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.
LOUISIANA:
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.
COLORADO:
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.
MAINE:
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.
MARYLAND:
Any person who knowingly and willfully
presents
a false or fraudulent claim for payment of a loss
or benefit or
who 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.
DELAWARE:
Any person who knowingly, and with intent to
injure, defraud or deceive any insurer, files a statement of
claim containing any false, incomplete or misleading
information is guilty of a felony.
MINNESOTA:
A person who files a claim with intent to defraud
or helps commit a fraud against an insurer is guilt of a crime.
DISTRICT OF COLUMBIA: WARNING:
It is a crime to provide
false or misleading information to an insurer for
the purpose of
defrauding the insurer or any other
person. Penalties include
imprisonment and/or fines. In
addition, an insurer may deny
insurance benefits if false
information materially related to a
claim was provided
by the applicant.
NEW HAMPSHIRE:
Any person who, with a purpose to injure,
defraud, or deceive any insurance company, files a
statement
of claim containing any false, incomplete, or misleading
information is subject to prosecution and punishment for
insurance fraud, as provided in RSA 638:20.
FLORIDA:
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.
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 WARNING NOTICES (CONT.)
For use with Claim Forms
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
NEW MEXICO:
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 civil
fines and criminal
penalties.
TENNESSEE:
It is a crime to knowingly provide false,
incomplete or misleading information to an insurance
company
for the purpose of defrauding the company.
Penalties include
imprisonment, fines and denial of
insurance benefits.
NEW YORK:
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 for each
such violation.
TEXAS:
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.
OHIO:
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.
VIRGINIA
: It is a crime to knowingly provide false,
incomplete
or misleading information to an insurance
company for the
purpose of defrauding the company.
Penalties include
imprisonment, fines and denial of
insurance benefits.
OKLAHOMA: WARNING: Any person who knowingly, and with
intent to injure, defraud or deceive any insurer, makes any claim
for the proceeds of an insurance policy containing any false,
incomplete or misleading information
is guilty of a felony.
WASHINGTON:
It is a crime to knowingly provide false,
incomplete, or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines, and denial of insurance
benefits.
OREGON:
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 may be guilty of insurance fraud.
RHODE ISLAND and WEST VIRGINIA:
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.
PENNSYLVANIA
: 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
subjects such person to criminal and civil
penalties.
ALL OTHER STATES:
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 subjects such person to criminal and civil
penalties.
PUERTO RICO:
Any person who knowingly and with the
intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a
loss
or any other benefit, or presents more than one claim
for the
same damage or loss, shall incur a felony and,
upon
conviction, shall be sanctioned for each violation with
the
penalty of a fine of not less than five thousand dollars ($5,000)
and not more than ten thousand dollars ($10,000), or a fixed
term of imprisonment for three (3)
years, or both penalties.
Should aggravating circumstances
are present, the penalty thus
established may be increased
to a maximum of five (5) years, if
extenuating circumstances are present, it may be reduced to a
minimum of two (2) years.
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Cancer Claimform Group Cancer Claims (Aflac Insurance)

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Completed 16 July 2020

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