Fillable Faster, Easier Online Claim Filing Instructions (City of Plano)

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Faster, Easier Online Claim Filing Instructions (City of Plano)

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BN-608-1117, Hospital GAP or Hospital Indemnity Claim Form 1
American Fidelity Assurance Company | Mail to: Worksite Group Benefits Department
P.O. Box 25160 | Oklahoma City, Oklahoma | 73125-0160
Toll Free Phone # 1-800-662-1113
Toll Free Fax # 1-800-818-3453
americanfidelity.com
1. Complete the Statement of Insured.
2. Complete the Authorization to Disclose Protected Health Information.
3. Attach itemized bills with diagnosis from each of your providers with a complete breakdown of charges for each date
of service.
4. HOSPITAL GAP ONLY: If you are ling for hospital benets, please attach a copy of the explanation of benets (EOB)
from your primary medical carrier. The benet is based on your Co-pay, Coinsurance, and Deductible and your EOB is
the statement that provides us with this information.
5. Mail or fax the completed forms to American Fidelity at the address or fax number listed above.
Reduce your claim processing time and receive your money faster when you file online or through AFmobile®.
Through your online or mobile account, you can file your claim, check claim status, sign up for notifications,
update personal information, enroll in direct deposit, view your detailed policy, and much more!
Faster, Easier Online Claim Filing Instructions
Hospital GAP or Hospital Indemnity Claim Filing Instructions Account Number:
Download AFmobile from the Apple App Store or Google Play
Two Easy Ways to Register
Online at americanfidelity.com
Stop here! If you want to receive your money faster, register your account and le online or through our mobile app.
!
Claim Filing Instructions for Mail or Fax:
This is not the quickest option! However, if you choose to file a paper claim by mail or fax, please complete this packet in full to
avoid delays in your claim processing.
For the fastest claim turnaround time, please complete and submit separate claim forms for each diagnosis.
For example, if you are filing for knee pain and pregnancy, please submit a separate form for each diagnosis.
To receive updates on the on the status of your processed or paid claims, visit americanfidelity.com/myaccount and select your
communication preferences. Or, you may contact us at the number atop this form with questions regarding your claim.
To set up direct deposit with American Fidelity, provide all required information below with your submitted claim. You may
also enroll in direct deposit through your online account.
I authorize American Fidelity Assurance Company (AFA) to initiate credit entries to my account as indicated. I also authorize
AFA to debit my account for any deposits made in error. This authorization remains effective and in full force until AFA
receives written notification from me of its termination in such time and in such manner as to afford AFA and the Depository
a reasonable opportunity to act on it. Please notify AFA immediately if your depository information has changed.
Signature: _______________________________________
You must provide the following information:
Routing Number: _______________________________________
Account Number: _______________________________________
Your Money Direct, Your Money Faster. Enroll in Direct Deposit.
Routing Number Account Number
SB-32082-1117
BN-608-1117, Hospital GAP or Hospital Indemnity Claim Form 2
American Fidelity Assurance Company | Mail to: Worksite Group Benefits Department
P.O. Box 25160 | Oklahoma City, Oklahoma | 73125-0160
Toll Free Phone 1-800-662-1113
Toll Free Fax 1-800-818-3453
americanfidelity.com
STATEMENT OF INSURED
To be completed by Employee.
Important! For the fastest claim turnaround time, please complete and submit separate
claim forms for each diagnosis. This will improve your claim wait time.
PATIENT INFORMATION
To be completed by Employee.
Full Name: (last, first, middle initial)
Date of Birth: / /
Social Security Number: / / Account Number:
Mailing Address: (P.O. Box or street, city and zip code)
Telephone Number (including area code)
: Email Address:
Employer Name:
For whom do you make this request? r Self r Spouse r Child r Other
Full Name: (last, first, middle initial) Date of Birth: / /
Where was treatment provided?
For the fastest claim turnaround time, please complete and submit separate claim forms for each diagnosis.
r Physician Office r Hospital
If hospital, select type of care:
r Outpatient Care r Inpatient Care
If hospital confined, please provide:
Hospital(s): Admitted: Discharged:
Hospital(s): Admitted: Discharged:
Claim is due to: r Illness r Accident r Pregnancy
If illness, date of onset: / /
Describe injury or illness in detail.
If pregnancy, date first diagnosed: / /
I certify this information is true and correct.
Signature: Date:
M-3621-0718
American Fidelity Assurance Company | Mail to: Worksite Group Benets Department
P.O. Box 25160 | Oklahoma City, Oklahoma | 73125-0160
Toll Free Phone 1-800-662-1113
Toll Free Fax 1-800-818-3453
americandelity.com
AUTHORIZATION TO DISCLOSE INFORMATION
INCLUDING PROTECTED HEALTH INFORMATION
The purpose of this form is to allow American Fidelity Assurance Company (AF) to obtain data including but not limited to
employment information, nancial information, and protected health information about me, from any party holding that
information. Once obtained, AF may use this data to review or process benets, conrm policy information, or otherwise review
or process information related to my Customer relationship with them.
I hereby authorize the entities specied below to disclose any information about me or my dependents’ health or nancial
situation including my or my dependents’ entire medical record and history of treatment for physical and/or emotional illness
to include psychological testing, except psychotherapy notes, to individuals representing AF who are involved in determining
whether I am eligible for benets under my insurance coverage. Those so authorized are: a) licensed physicians or medical
practitioners; b) hospitals, clinics or medically-related facilities; c) health plans; d) Veteran’s Administration; e) past or present
employers; f ) pharmacy; g) insurance companies; h) the Social Security Administration; i) retirement systems; j) Department
of Motor Vehicles, k) banks or nancial institutions and l) Workers’ Compensation Carrier. Colorado state law prohibits the
redisclosure or reuse of information disclosed about a Colorado resident under this authorization.
NOTICE: Information authorized for release may include information on communicable or venereal diseases such as hepatitis,
syphilis, gonorrhea, HIV/AIDS (Human Immunodeciency Virus/Acquired Immune Deciency Syndrome) or other conditions for
which you may have been treated.
I understand that AF may not condition payment of claims, enrollment, or eligibility for benets on whether I sign this
authorization. I understand that I may refuse to sign this authorization; however, if I do not sign the authorization, my failure to
sign the authorization may result in a denial or an inability to pay benets under my policy if my failure to sign results in AF not
having enough information to process my benets. I understand that I may revoke this authorization at any time by writing to
American Fidelity Assurance Company, PO Box 25160, Oklahoma City, OK 73125-0160 or by calling, toll-free,
1-800-662-1113. I understand that my right to revoke this authorization is limited to the extent that: AF has taken action in reliance
on the authorization; or, the law provides AF with the right to contest my insurance coverage or a claim under my insurance
coverage. A copy of this authorization will be as valid as the original.
I understand that if protected health information is disclosed to a person or organization that is not required to comply with
federal privacy regulations, the information may be redisclosed and no longer protected by the federal privacy regulations.
In addition to the types of information described above, I also authorize American Fidelity to access any other type
of information deemed necessary to investigate my claim. This information includes but is not limited to nancial information,
information submitted or related to insurance claim(s) or insurance coverage(s) and employment records. Any party holding this
information is hereby authorized to release it to American Fidelity.
For health insurance coverage this authorization will expire twenty-four months from the date it is signed or upon termination
of my insurance policy, whichever occurs rst. For insurance coverage other than health insurance, this authorization will expire
twenty-four months from the date it is signed or upon expiration of my claim for benets, whichever occurs rst.
AF Account# Printed Name of Patient Patient’s Date of Birth
Signature (Patient) or Personal Representative (if applicable) Date Signed
Relationship of Personal Representative to Patient (if applicable)
If authorization is supplied by a personal representative, a description of the authority to act on behalf of the Insured must be included.
Please retain a copy for your personal records, or you may request a copy from our Company.
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BN-608-1117, Hospital GAP or Hospital Indemnity Claim Form 4
American Fidelity Assurance Company | Mail to: Worksite Group Benefits Department
P.O. Box 25160 | Oklahoma City, Oklahoma | 73125-0160
Toll Free Phone 1-800-662-1113
Toll Free Fax 1-800-818-3453
americanfidelity.com
Claim Form Fraud Statements
The following fraud language is attached to, and made part of, this claim form. Please read and do not remove this page from this claim form.
If you live in a jurisdiction not mentioned below, the following applies to you: Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benet is guilty of a crime and may be subject to nes and connement in prison.
Alabama - Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benet or who
knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to restitution,
nes, or connement in prison, or any combination thereof.
Alaska - A person who knowingly and with intent to injure,
defraud, or deceive an insurance company les a claim
containing false, incomplete, or misleading information may be
prosecuted under state law.
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.
Arkansas, District of Columbia, Louisiana, Rhode Island and
West Virginia - Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benet or knowingly
presents false information in an application for insurance is
guilty of a crime and may be subject to nes and connement
in prison.
California and Texas - For your protection California and
Texas law requires the following to appear on this form: Any
person who knowingly presents false or fraudulent claim for
the payment of a loss is guilty of a crime and may be subject to
nes and connement in state 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,
nes, 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.
Delaware, Idaho and 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.
Florida - Any person who knowingly and with intent to injure,
defraud, or deceive any insurer les a statement of claim or an
application containing any false, incomplete, or misleading
information is guilty of a felony of the third degree.
Indiana - A person who knowingly and with intent to defraud
an insurer les a statement of claim containing any false,
incomplete, or misleading information commits a felony.
Kentucky - Any person who knowingly and with intent
to defraud any insurance company or other person les 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.
Maine, Tennessee, Virginia and 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 may include imprisonment, nes or a denial
of insurance benets.
Maryland - Any person who knowingly or willfully presents
a false or fraudulent claim for payment of a loss or benet or
who knowingly or willfully presents false information in an
application for insurance is guilty of a crime and may be subject
to nes and connement in prison.
Minnesota - A person who les a claim with intent to defraud
or helps commit a fraud against an insurer is guilty of a crime.
New Hampshire - Any person who, with a purpose to injure,
defraud, or deceive any insurance company, les 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.
New Jersey - Any person who knowingly les a statement of
claim containing any false or misleading information is subject
to criminal and civil penalties.
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.
Ohio - Any person who, with intent to defraud or knowing
that he is facilitating a fraud against an insurer, submits an
application or les a claim containing a false or deceptive
statement is guilty of insurance fraud.
Pennsylvania - Any person who knowingly and with intent
to defraud any insurance company or other person les 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 benet, 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 by a ne of not less than
ve thousand dollars ($5,000) and not more than ten thousand
dollars ($10,000), or a xed term of imprisonment for three (3)
years, or both penalties. Should aggravating circumstances
[be] present, the penalty thus established may be increased to
a maximum of ve (5) years, if extenuating circumstances are
present, it may be reduced to a minimum of two (2) years.
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Faster, Easier Online Claim Filing Instructions (City of Plano)

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Completed 14 July 2020

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