rev. 4/09
Claims Authorization to Obtain Information
Instructions for completing this Health Insurance Portability and Accountability Act of 1996
(HIPAA) compliant form:
1. All areas of this form should be completed.
2. This form must be signed and dated by the claimant/patient below.
3. IMPORTANT: If you are filing a claim on behalf of a deceased, please check here
4. If you are the Authorized Representative, please sign below and indicate your relationship to the
claimant/patient/deceased. In addition, include a copy of the legal document(s) authorizing you to
act on their behalf.
5. Fax this form to 1-877-442-3522 or return the form to Aflac, Attn: Claims Department, Worldwide
Headquarters, 1932 Wynnton Road, Columbus, GA 31999, as soon as possible in order to expedite
claim review.
Policyholder Name: Policy Number(s): Date of Birth:
Policyholder Address:
Claimant/Patient Name (if different from named policyholder listed above):
Date of Birth:
American Family Life Assurance Company of Columbus (Aflac)
Worldwide Headquarters • 1932 Wynnton Road • Columbus, Georgia 31999
1-800-992-3522 • aflac.com
Signature of claimant/patient, guardian or authorized representative Date
Printed name of claimant/patient, guardian or authorized representative Relationship
I understand that:
1. Protected health information may include information and records protected under Federal and State Law
such as: alcohol, drug abuse, mental health, AIDS or HIV testing or treatment, or the presence of a
communicable or noncommunicable disease.
2. My treatment, payment or eligibility for benefits may not be conditioned on signing this authorization.
3. I understand that I may revoke this authorization at any time by writing to Aflac, Claims Department,
Worldwide Headquarters, 1932 Wynnton Road, Columbus, GA 31999, except to the extent that:
a. Aflac has taken action in reliance to this authorization, or
b. Other law provides Aflac with the right to contest a claim under the policy or the policy itself.
4. If the requestor or receiver is not a health plan or health care provider, the released information may no
longer be protected by federal privacy regulations and may be redisclosed.
5. It is recommended I retain a copy of this signed form for my records, understanding that a copy is as valid
as the original.
This authorization shall be valid for a period of two
years from the sign date unless a lesser time frame is
indicated. Alternate Expiration Date:
Name and Address of health care provider(s),
company, or individual authorized to release
the requested information:
(this section will be completed by Aflac):
Purpose of Disclosure: Evaluate claims for benefits
during the time this authorization is valid.
S-00216
I, or my authorized representative, request that information regarding my past, present, or future physical or
mental health condition (excluding psychotherapy notes), employment, other insurance coverage, or any other
nonmedical facts be released to American Family Life Assurance Company of Columbus (Aflac) or any
person or entity acting on its part. This could include, but is not limited to, any medical professional, medical
care institution, insurer (including Aflac, with respect to other Aflac coverages), reinsurer, government agency
(including departments of public safety and motor vehicle departments), consumer reporting agency or
employer.
