Fillable Wellness Claim Form

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Wellness Claim Form

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Post Office Box 84075 * Columbus, GA. 31993
Phone (800) 433-3036 * Fax (866) 849-2970
groupclaimfiling@aflac.com
WELLNESS 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 myclaim.
Policyholder’s Signature:
Date:
Claimant’s Signature:
Date:
POLICYHOLDER/PATIENT INFORMATION
EMPLOYER’S NAME
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
ZIP CODE
POLICYHOLDER'S PHONE NUMBER
PATIENT’S NAME
RELATIONSHIP TO THE POLICYHOLDER
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 ACCIDENT PLAN ONLY
☐ Annual Physical Exam
☐ Eye Examination
☐ Immunization
☐ Vision Screening
TESTS COVERED UNDER HOSPITAL INDEMNITY ONLY
☐ Annual Physical Exam
☐ HSN Strains (Herpes Simplex Virus)
☐ Immunization
☐ Non-diagnostic Vascular Screening
☐ Urinalysis
TESTS COVERED UNDER CRITICAL ILLNESS PLAN ONLY
☐ Breast Ultrasound
☐ Chest Xray
☐ Colonoscopy
☐ Hemocult Stool Analysis
☐ Skin Cancer Screening
☐ Stress Test (Bicycle or Treadmill)
☐
Thermography
TESTS COVERED UNDER ALL PLANS
☐ Biometric Testing
☐ Blood Screening
☐ Blood Test for Triglycerides
☐ Bone Marrow Testing
☐ CA 125 (Blood Test for Ovarian Cancer)
☐ CA 15-3 (Blood Test for Breast Cancer)
☐ CEA (Blood Test for Colon Cancer)
☐ Fasting Blood Glucose Test
☐ Flexible Sigmoidoscopy
☐ HIV (Human Immunodeficiency)
☐ HPV (Human Paillomavirus)
☐ Mammography
☐ PAP Smear
☐ PSA (Blood Test for Prostate Cancer)
☐ Serum Cholesterol Test (HDL and LDL)
☐ Serum Protein Electrophoresis (Myeloma)
☐ Ultrasound
PHYSICIAN INFORMATION
NAME
TELEPHONE NUMBER
ADDRESS
CITY
ZIP CODE
wb.agi.en.201804
Electronic Funds Transaction Authorization
Send to:
Continental American Insurance Company
Post Office Box 84075
Phone: (800) 433-3036 Fax (866) 849-2970
Columbus, Georgia31993
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 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 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
eft.agi.en.201803
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Wellness Claim Form

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Completed 2 July 2020

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