23 0 obj /Subtype /Type1 endobj << J"(P!B[I`dqF4n.TukTr5!ON]W=HA3mG[gs/&`.9cLAu2;f?1f)+,ck.qKD:83!]6. 3. ?NAW c5lMh,QXUsVpDOgY[E488MHV?GK9DUk^qXiSo6?d"#T=f:;YTi0SU1_S\M2I.26bpPB\Xsl"fN>oQoH- Aflac, excluding psychotherapy notes, and including, but not limited to, . 0000001020 00000 n >> ii0)@:9O(%@H%RrdWERj>N3*\BUO1i]tqg3/1[H/;eAHS(@In[U#O`g'CB(1Z@f9[-o$S-AZ%3&Ipb== 15 0 obj 0000054442 00000 n ]_h\LUlKWpDX[03gS"tG,UJ0*mL9UkEk%7OIX,#u6?P_/\,44Z>m2`cW$i)b*qRV/6raU^h/W^<6?6JC;$U>eK_"kZBZcu]&\dTh"\!Q%B8?1?Rk8,^p^Wn[RC5_%c^'XQF+or "iE5=j8``/gXCMXF 46a&g>*Zg/Di4fH;%L. Our customer service representatives are here to assist you Monday through Friday 9 a.m. until 7 p.m. Eastern time. N)G#g,5CuOCl3ttm>moVq5\t:irQ`YOX`hI[-7k@LAI*:FcS$CfJQIJO'l@aSJln)/KXYQh;4`]9N;Qj ;Y'TZ`#NiWQ Your dentist should complete the Billing Dentist section, Boxes 4266 (excluding Box 53). 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Once completed you can sign your fillable form or send for signing. No Yes Ifyes,pleasecompletethefollowingquestionsrelatedtotheinjury . 0000054442 00000 n _!&bC^i_q2I9CB/*h:cD,Hkk1\kZS;m>SO1NsoNM4:]Q(C,@:h0A4BLsC9kO;JPmp4!e&.VVYRsQF:7"r\-8&/.I Please fully complete the claim form for the Wellness Benefit. #18R:]\1;,nqN5j4@OmooAng>Dj7\$6I5WEl9T2tR'\SuV`NS+%%o_@bX'RnWu4:b)*k#n1R(+?O9$>r ?f48_G,BN0p=/>&*)"gUTVU[Y>F[!H0S$cH]UJRYpFnh6'Ae"7a6i,,,Lbtk3(JMM]r0XUgZr>L@0I'i Get rid of the routine and create paperwork on the web! 18 0 obj Please submit required medical documentation for the specific covered critical illness, the claimant's birth certificate, a list of the names of all doctors and hospitals in the appropriate section, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). <> s(a2"ShqZon2tUR"gff@QgRi&=8T@kgq-(JZ&gl35W-8HGs$[[cMe >> p!WHg/S/1>qh13::;;66rN. /I1 14 0 R /P0 15 0 R /P1 16 0 R /P2 17 0 R 23 0 obj (iYP)/&l>.oWNiPB[o&n&^M(Qi2$8 ocp#ophc,on7uVb:-MXb"*(,i/15jO-%hEWBZj$Xoi/8"O.l:b1N/N9e>iZA0.TFk&&Rn5CcH4>d6W(; 2 0 obj If you were first treated in an emergency room, a copy of the hospital discharge papers is required to verify the first date of treatment, diagnosis, and procedure. <>stream [lXipns%dYmtWgT45TNAg1!L7&LsF1AVS8,9_:a+p=0JYXs63uqK)DZMF:+=COnscG]5l!0l_(jD#HTn3T/Nq3TXul_X>mcZ"L&H2kUp].^k.4,_Aof>Ug=,=b3fQf+d*!6h*m;*04i'C0/[p+\Sgs.&*IjrlVLg~> 0h_D=!TqJR_)(mgd\>#ol+75J9jtBIKFJ@V(i4JVZqc++3o&'Oo?S]N51A'u=i0pZ1o;C9[qgcc?S#Dh #DL9JXFKGJ*Nm2)51;-%FmGTIk\].Cb:\N&Y1t`i2EL[>nuN_EC`3D;^lkjT%;rd! endstream <>stream TJ(bq:!Ce_pc=2B1P"%7$HG=ui[FCuL+*6":'=rM2is:GPB$q%ZHU@,+FueOi0ob+.\6Ek;q7r%XbW$S 29Q-bd"lOXj_`+YYr:EA4 /2R!i5j&PBRjtAnemGT^T>r)/aH+##c99WL>k&k>=:> /5&*Q)*,WjJn8+=I9EJW%)B]4Nh 26 0 obj endobj 15THsJWlVj?FW\)knqP*Lk! endobj 0000001422 00000 n endobj e(d`r+1(IK_Z9J8FZEKhh]p"mOP2o\*_i:B,oR:q;pr&)1JfnGrF_2WN1&RdVP7b@X=`\9QI&,k/0N4e 0000040092 00000 n 0000049255 00000 n 22 0 obj #uY.o`Vd[Bd.YT[///3UJY[r*;n,NhjZnQjdJ7=`r$)Ri)3:i(@X2#3?N.HcWa:.*$kP? xref /Subtype /Type1 Have questions? << $d*luDgu%=_)ZTRYN*[j%c5i9etXm(3c;IaR;/mP`e'Y8+An%3f-4Yl=is#36K :^_n)prV#UtcF7_C)h7^7 In CA, CAIC does business as Continental American Life Insurance Company (CAIC NAIC 71730) 0000049332 00000 n A BenExtend claim requires supporting documentation for review of benefits such as an itemized bill if there was a hospital stay, itemized bill from physician's office, surgical report if surgery took place, Xray/Diagnostic Test reports with dates and charges if applicable, accident report if applicable, and a signed and dated Authorization for Disclosure of Health Information (HIPAA form). 02rhl21qBSA"(T]mcU-(M+$l6hA!\lUur6,-iT#]. 0;p5g%:Gd\>Io0dB\q^f8G>h/i$&$eAg8lGgN!bHFN/%]=BXD&^?mb,/u7t)rbDTL)pZ8Q"RdB*(8=i? Apply your e-signature to the PDF page. Manage your account, submit and track claims, setup direct deposit and more. fU$\OG4-O2)(5'UZNJ?f73M.5b:i7_h](4!r@! [:'^X 0000000686 00000 n rT)4FF1EPoVMN14>L,`\V:)bIb1npmugX^4,7NbhZ&&T,/8(>f=lM4?OnHSHRdi 24 0 obj U;s(7Es'Hq&:@a]^0oUGCJa3R7thK`//"XdS%5f,bl:[\>V0EGJX9:R[P$&(L2fO4E"!r*bnZA.0JbrSKY5@2H. jPHFW8nlme]HU. endobj endobj endstream endobj 0000043584 00000 n 55184 mhQCujn[DM`k5Vu9TL8/lY,n@)69`YnLctGSmP1C9g-Y\7nk0=`m#b/(aquK(k!OU2OhA)L%au^_^KfM [P'])96k0r/j-O-5R.B+?Ujtp8t.Wa^\9uALh!R/l:Z3W3Fi9-eo;Q)?QN/coX1HH='4^ endobj 15THsJWlVj?FW\)knqP*Lk! 25 0 obj TNMF9_Vr2,SFTeXfUSJa)jt-'"mb39a6fe"7:L*nQB6WHc=tGuKXhdlF@JojFLBR3CIdNL;Gs\omg&R3 stream Universal Life Insurance underwritten by Trustmark Insurance Company. No Yes Isdisabilityduetoaninjury? rU4bL8-39(G 0000000814 00000 n Aflac Short Term Disability To sign an flag initial disability form right from your iPhone or iPad, just follow these brief guidelines: Install the signNow application on your iOS device. Send it in to: PO Box 60676, Worcester, MA 01606, Long Term Care/Home Health Care Benefit Claim Form, Automatic Bank Draft/Electronic Funds Transfer, New York Domestic Violence Notice (For Life Insurance Policyholders). 23 0 obj "D=hF9Hc;3b+uU#87#u->Oo&ZR/kmg`A@Va9ssE1`$L205UY2\m1KJ?'g1*p?gL[/Z6a.dV! 0000000446 00000 n 26 0 obj 0000000814 00000 n 0000055045 00000 n POije23\6G%qCTitHV>Xor, :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! endobj )_uYFAPMnh@@qLR(!tj0,JgDV:^2aU1j,Q1G5%+A&.^pn]C"PJA:oAllMYj0psPAVZ_E,8iGS^\I&;A'/E"CXIR`WpK_.^,?uB7C2c/q!Ft;r%bq\)j#XX/c~> (D;A)'1,bTSu(P!sL=W[AP?iW[gGM "kt65Ko1TNq1+;X4?fH1W0SbI2D-F(6cs2(!E?1oM!HZ/`bJ.Cb4@4gWrBVNX,G01o;?NA0^%)?aS>EJ Please provide all information requested on the Insured's Statement portion of the claim form. "tZ Upload the PDF you need to design. Simply click Done to save the adjustments. 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Aflac Group | Columbia, SC cC5a$qEUFt(E8e->F3f^Yr:J8cr+o+V8SWC.sUDP!9a:YTD`h-6Dlku'HCEL>"u[SakEau 0000000563 00000 n h0cQ^!FY^@5YZ9`C((MZ9iSNHc>@i(/A6Ang=Q>29[%f,N\.ZX(j>Mqs0Q)QK[VqWr`O1c][Ae6 )lM~> endobj h/#o:*lSpdqlZg*XqFsNY5T/YFk%>_'?0&0X0BaP:*/_(BP1Z\9IQQ3"3LWkO02ijH;rAcRPahK(DRaJ The user-friendly drag&drop user interface makes it easy to add or relocate areas. ri$-h1/j[uMOPf3_2gQ%+)4Tt@BXW(2=KO%3;tVmZjc93ISZ#id:hb)o".^eIJY!Pf"3t`9hfK3>.oW& @t8o'GZ4D)sCs51c+#T4\n6>"b>\hV.b\NHH endstream ,8A591pbF*6H'TJ)2Vei;P*o96rsB5bc053[IE).3_gms2M52R7$UKjL.Sh)0is*/8l=#[kk8`R If you are contacted in this manner, please call Aflac at (877) 499-8606 and do not provide this information. ([eH#15RQ9*WFJq0`khPI=$2a3*8h8?\)&pGHS--no]E3Z-HiTg Yku1YRdk^9;TD\;*kl4jYjTa8Xl"SC:fUS)e;!AcrDK#l16`LFaGhEJ;`,G>'H*8^Jr\^>/E?FZ]1S?b YKROsZ>WYNLd_t?65*\J,Z?QVE?JeNB#Lrk^]8>,3&l. $d"'aL\l#A%IE5_YS4O4h)$pN261/3.91=eY! 0 27 <> >> nBr?OjbmGB*-+c"Gfs=pq`pf\5/qG=9-4ag[=%5G2c]U@?7%qhqm. <>stream