Fillable WEL LNESS AND HEALTH SCREENING CLAIM FORM Failure

Fill Online, Printable, Fillable, Blank WEL LNESS AND HEALTH SCREENING CLAIM FORM Failure Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

WEL LNESS AND HEALTH SCREENING CLAIM FORM Failure

On average this form takes 15 minutes to complete

The WEL LNESS AND HEALTH SCREENING CLAIM FORM Failure form is 2 pages long and contains:

  • 1 signature
  • 28 check-boxes
  • 41 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Send to:
Continental American Insurance Company
Post Office Box 84080
Columbus, GA 31993-4080
Phone: (800) 433-3036
Fax: (706) 243-7577
Email: aflacgroupclaimsus@aflac.com
WEL
LNESS AND HEALTH SCREENING CLAIM FORM
Failure to complete all sections may result in delayed processing of this claim.
Review your policy for specific benefits covered under your plan.
AUTHORIZATION
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 have checked the answers given by myself and they are correct. I AUTHORIZE any physician, medical practitioner, hospital, clinic other medical or medically
related facility, insurance company, consumer report agency, or employer having information available as to diagnosis, treatment and prognosis with respect
to any physical or mental condition and/or treatment and any non-medical information for me, to give to Continental American Insurance Company or its legal
representative, any and all such information. This information is to include, but is not limited to information pertaining to diagnosis, care or treatment for
psychiatric disorder, drug or alcohol abuse, treatment or prescriptions, testing and/or treatment of HIV (AIDS virus) and/or other sexually transmitted diseases,
including case history and medical antecedents. I UNDERSTAND the information obtained by use of the Authorization will be used by Continental American
Insurance Company to determine eligibility for benefits under an existing certificate. Any information obtained will not be released by Continental America
Insurance Company to any person or organization EXCEPT to re-insuring companies, or other person or organization performing business or legal services in
connection with any claim, or as may otherwise lawfully required or as I may further authorize. I KNOW that I may request to receive a copy of this
Authorization. I AGREE that this authorization shall be valid for the duration of my claim.
Policyholder’s Signature:
_
Date:
Claimant’s Signature: _
Date:
POLICYHOLDER/PATIENT
INFORMATION
UNIVERSITY OF CALIFORNIA GROUP #25796
POLICYHOLDER’S EMAIL ADDRESS
POLICYHOLDER’S NAME
POLICY NO.
SSN/ EMPLOYEE ID
DATE OF BIRTH
GENDER
POLICYHOLDER’S ADDRESS
☐
CHECK BOX IF THIS IS A PERMANENT ADDRESS CHANGE
CITY
STATE
ZIP CODE
POLICYHOLDER'S PHONE NUMBER
PATIENT’S NAME
PATIENT’S DATE OF BIRTH
PATIENT’S GENDER
*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 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).
HEALTH SCREENING INFORMATION
DATE HEALTH SCREENING TEST WAS PERFORMED:
WHICH HEALTH SCREENING TEST DID YOU HAVE PERFORMED:
TESTS COVERED UNDER CRITICAL ILLNESS PLAN ONLY
TESTS COVERED UNDER HOSPITAL INDEMNITY PLAN ONLY
☐
Biometric Testing
☐ Blood Test for Triglycerides
☐ Bone Marrow Testing
☐ Breast Ultrasound
☐ CA 125 (Blood Test for Ovarian Cancer)
☐ Chest X-ray
☐ Stress Test (Bicycle or Treadmill)
☐ Thermography
☐ DNA Stool Analysis
☐ CA 15-3 (Blood Test for Breast Cancer)
☐ CEA (Blood Test for Colon Cancer)
☐
Fasting Blood Glucose Test
☐ Flexible Sigmoidoscopy
☐ Colonoscopy
☐ Hemocult Stool Analysis
☐ Mammography
☐ Cervical Cancer Screening
☐ PSA (Blood Test for Prostate Cancer)
☐ Serum Cholesterol Test (HDL and LDL)
☐ Serum Protein Electrophoresis (Myeloma)
☐ Spiral CT Screening for Lung Cancer
☐ Mammography
PHYSICIAN INFORMATION
NAME
TELEPHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
wb.agi.en.201804
EMPLOYER’S NAME
Electronic Funds Transaction Authorization
Send to:
ContinentalAmericanInsurance
Company Post Office Box 84080
Columbus, GA 31993-4080
Phone: (800) 433-3036
Fax: (706) 243-7577
Email: aflacgroupclaimsus@aflac.com
Authorization Agreement for Direct Deposit
I would like to: Start Stop Change direct deposit of my claimpayment(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’sName (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:
ContinentalAmerican Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwritesgroup 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 groupssitused 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
EFT Form 2016
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

WEL LNESS AND HEALTH SCREENING CLAIM FORM Failure

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 November 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document