Fillable HEALTH SCREENING/WELLNESS RIDER BENEFIT CLAIM KIT (Cherokee County, Georgia)

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HEALTH SCREENING/WELLNESS RIDER BENEFIT CLAIM KIT (Cherokee County, Georgia)

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HEALTH SCREENING/WELLNESS RIDER BENEFIT CLAIM KIT
INSTRUCTIONS FOR FILING A HEALTH SCREENING/WELLNESS CLAIM
1. Please complete Section 1 - Claimant’s Statement.
2. Please complete Section 2 - Testing Information.
3. Please review, sign and date the form.
4. Attach medical documentation which indicates the type of test performed and the date the test was performed.
SECTION 1 – CLAIMANT’S STATEMENT (Please Print)
Insured Name (Last, First) Claimant’s (Patient) Name Policy/Certicate#
Address (City, State, Zip)
Telephone Number Claimant’s Date of Birth (mo-day-yr) Insured’sSocialSecurity#
SECTION 2 – TESTING INFORMATION
DATE TEST PERFORMED
WHICH SCREENING TEST DID YOU HAVE PERFORMED?
X
Signature of Claimant Printed Name Date
For Claim questions, please call toll-free
1-888-453-5120
916-710 12/15
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. By signing below, you agree under penalties of perjury that the information in this statement is complete and true to the
best of your knowledge.
Please refer to the “Fraud Warning Notices” insert for your state.
q
Stress Test on a Bicycle or Treadmill
q
Serum Cholesterol Test or Lipid Panel
(total cholesterol count)
q
CA 15-3 (Blood Test for Breast Cancer)
q
Serum Protein Electrophoresis (myeloma)
q
CEA (Blood Test for Colon Cancer)
q
PSA (Blood Test for Prostate Cancer)
q
Fasting Blood Glucose Test
q
CA 125 (Blood Test for Ovarian Cancer)
q
Hemocult Stool Analysis
q
C-Reactive Protein
q
Thermography
q
Bone Marrow Testing
q
Mammography/Breast Ultrasound
q
Blood Test for Triglycerides
q
Flexible Sigmoidoscopy
q
Pap Smear (including ThinPrep Pap Test)
q
Chest X-Ray
q
Colonoscopy
q
Homocysteine Level
q
Electron Beam Tomography
q
Electrocardiogram (EKG)
q
Oral Cancer Screening (using ViziLite
or other similar test)
q
Biopsy for Skin Cancer
BOSTON MUTUAL LIFE INSURANCE COMPANY
HOME OFFICE: 120 Royall Street
•
Canton, MA 02021
ADMINISTERED BY: PHILADELPHIA AMERICAN LIFE INSURANCE COMPANY
PO Box 34952
•
Omaha, NE 68134-9832 – TEL 1-888-453-5120
•
FAX 1-888-453-5127
FAMILY MATTERS. NO MATTER WHAT.
Please note: Not all tests listed above may be eligible for coverage. Please refer to your Policy/Certicate for a list of covered tests.
PROTECTING YOUR INFORMATION
To protect your nonpublic personal information, we maintain: physical, electronic and procedural safeguards.
COLLECTING INFORMATION
We collect information about you in order to conduct business. Such uses are: to process requests for insurance products, to
provide customer service, to process claims, to fulfill legal and regulatory requirements and for other lawful purposes. We
collect this information from you, as well as from other sources. We restrict access to your information to those working on
our behalf who have a need to know it in order for us to provide products and services to you. We require them to secure the
information and keep it confidential.
4 Information we collect may include all the information you share with us including, for example, your:
• name • employer name and income
• address • beneficiary data
• telephone number • financial account numbers
• date of birth • medical information
• social security or tax identification number • and other information you share with us
4 We may also collect data we receive from other sources, as allowed by law, which may include:
• medical information
• consumer report information in accordance with
the Fair Credit Reporting Act
SHARING INFORMATION
We do not share information about our customers or former customers with anyone, except as permitted or required by law.
4 We may share your information with third parties without your authorization as permitted by law. Such information is
used on our behalf by these third parties to:
• process or service your insurance transactions
with us
• perform underwriting, administrative, account
maintenance and claims functions
4 We may also share your information with:
• a consumer reporting agency in accordance with the Fair Credit Reporting Act
• a third party to comply with federal, state or local laws, subpoenas, or summonses
• regulators
• or as otherwise permitted or required by law.
Third parties receiving information from us are required to: keep it confidential and to comply with all applicable federal and
state privacy laws.
ACCESS TO YOUR INFORMATION WE HAVE IN OUR RECORDS
You have the right to request access to all the information we have on you. You must make your request in writing at the
address below.
AMENDMENTS TO YOUR INFORMATION
You have the right to request an amendment, correction or deletion of information which we hold about you which you believe
may be inaccurate. We are not obligated to make updates to your data based on your request. You must make the request in
writing and state the reasons you are requesting the change. Write us at the address below.
If you have questions about this notice or would like more information about our privacy policies, please write us at:
Boston Mutual Life Insurance Company
Attention: Privacy Office
120 Royall Street • Canton, MA 02021
420-012 3/15
• participant information from organizations that purchase
products or services from us for the benefit of their members
or employees, such as group insurance
• information to assist us in complying with state and federal
laws
• provide customer service or reinsurance coverage
• prevent fraud
• perform other business functions on our behalf
NOTICE OF INFORMATION PRIVACY PRACTICES
Boston Mutual Life Insurance Company
(Herein referred to as “we”, “us”, “our”)
FAMILY MATTERS. NO MATTER WHAT.
FRAUD WARNING NOTICES – For Use with Claim Forms
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
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:
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: 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
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: Any person who knowingly, and with intent
to injure, defraud or deceive any insurer, les a statement of
claim containing any false, incomplete or misleading infor-
mation is guilty of a felony.
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 nes. In addition,
an insurer may deny insurance benets if false information
materially related to a claim was provided by the applicant.
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.
IDAHO: Any person who knowingly, and with intent to
defraud or deceive any insurance company, les a statement
of claim containing any false, incomplete, or misleading
information is guilty of a felony.
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.
LOUISIANA: 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.
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, 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 NH Rev.
Stat. Ann. §638:20.
see other side
BOSTON MUTUAL LIFE INSURANCE COMPANY – 120 Royall Street
|
Canton, MA 02021
|
800.669.2668
|
www.bostonmutual.com
916-737 1/17
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.
NEW YORK: Any person who knowingly and with intent to
defraud any insurance company or other person les an
application for insurance of 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 ve
thousand dollars and the stated value of the claim for each
such violation.
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.
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.
OREGON: 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 may be 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 with the penalty of 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 are 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.
RHODE ISLAND: 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.
TENNESSEE: It is a crime to knowingly provide false, incom-
plete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties include
imprisonment, nes and denial of insurance benets.
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 nes and connement in state prison.
VIRGINIA: ANY PERSON WHO, WITH THE 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 HAVE VIOLATED THE STATE LAW.
WASHINGTON: It is a crime to knowingly provide false,
incomplete or misleading information to an insurance com-
pany for the purpose of defrauding the company. Penalties
include imprisonment, nes and denial of insurance benets.
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.
ALL OTHER STATES: 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.
FRAUD WARNING NOTICES – For Use with Claim Forms (cont.)
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
BOSTON MUTUAL LIFE INSURANCE COMPANY – 120 Royall Street
|
Canton, MA 02021
|
800.669.2668
|
www.bostonmutual.com
916-737 1/17
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HEALTH SCREENINGWELLNESS RIDER BENEFIT CLAIM KIT (Cherokee County, Georgia)

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Completed 23 June 2021

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