Loading
Form preview picture

Get Aflac Wellness Claim Form Online

DUCK Cancer Screening Wellness Benefit Claim Form Please read all instructions. Failure to follow these instructions will delay the processing of your claim. Do not include receipts statements or other documentation with this form. Your Aflac policy provides one Wellness Benefit per covered person per calendar year and this form is designed specifically for this benefit. Please check your policy for a list of covered wellness procedures or call 1-800-99-AFLAC 1-800-992-3522 for a Wellness Form specifically tailored for your policy. Claims for all other benefits covered under your Cancer policy must be filed separately using the Cancer Claim Form. If any of your wellness tests resulted in a diagnosis of cancer please submit your claim for cancer treatment separately using the Cancer Claim Form. If your Aflac policy also provides one Mammogram Benefit per calendar year please mark the appropriate box and indicate the date the mammogram was performed. Please check your policy for specific benefits covered under your policy. To receive your Wellness Benefit complete the form by following the instructions provided. Please print a separate form for each additional covered family member or call 1-800-99-AFLAC 1-800-992-3522 to request additional forms. Sign date and mail the completed form to the Aflac address shown below. Policyholder Information Middle Initial Policyholder s First Name M D Y ZIP of mailing address Birth Date Policy Number Patient Information First Name Relationship Last Name Sex Primary Dependent Child Spouse Male Female Patient s Wellness Exam Flexible sigmoidoscopy Treatment Date Thermography Colonoscopy Hemocult stool specimen Chest X-ray Virtual colonoscopy CEA blood test for colon cancer Pap smear - ThinPrep CA 125 blood test for ovarian cancer Breast ultrasound/Breast sonogram Pap smear Biopsy Mammogram Provide Actual Cost for Mammogram Physician Information Phone Number - Name Street Address City State ZIP Any person who knowingly and with intent to defraud any insurance company or other person files 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. Do not write on the form except as instructed. Incomplete forms cannot be processed and will be returned. Please do not fax this completed form to Aflac. Mark only wellness exam box es for test s that you had performed. POLICYHOLDER NAME POLICYHOLDER STREET ADDRESS CITY STATE ZIP BIRTHDATE American Family Life Assurance Company of Columbus Aflac Attn Claims Department 1932 Wynnton Road Columbus GA 31999-7251 1-800-99-AFLAC 1-800-992-3522 aflac.com 1-800-SI-AFLAC 1-800-742-3522 en espan l Z06197CA GA Some of the tests listed may not be covered under the Wellness Benefit of your policy. date the Pap smear was performed* Please check your policy for specific benefits covered under your policy.

How It Works

aflac forms accident wellness rating
4.8Satisfied
37 votes

Tips on how to fill out, edit and sign Aflac claim forms wellness online

How to fill out and sign Aflac cancer wellness claim form online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Tax, legal, business and other documents require higher of protection and compliance with the law. Our documents are updated on a regular basis according to the latest legislative changes. Plus, with us, all the details you include in the Aflac Wellness Claim Form is well-protected from loss or damage via cutting-edge file encryption.

The following tips will help you complete Aflac Wellness Claim Form easily and quickly:

  1. Open the template in our feature-rich online editor by clicking on Get form.
  2. Fill in the required fields which are colored in yellow.
  3. Press the green arrow with the inscription Next to move from one field to another.
  4. Go to the e-autograph solution to add an electronic signature to the template.
  5. Put the relevant date.
  6. Double-check the whole template to ensure that you haven?t skipped anything important.
  7. Click Done and download your new template.

Our solution allows you to take the whole procedure of executing legal documents online. As a result, you save hours (if not days or weeks) and eliminate additional expenses. From now on, submit Aflac Wellness Claim Form from home, place of work, or even while on the go.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Aflac covered accident list FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to aflac accident claim form 2022

  • aflac accident claim forms
  • aflac accident indemnity wellness benefit claim form
  • aflac accident wellness benefit
  • aflac accident wellness benefit claim form
  • aflac accident wellness claim form
  • aflac accident wellness claim forms
  • aflac accidental wellness claim form
  • aflac cancer claim form
  • aflac cancer claim forms
  • aflac cancer policy claim form
  • aflac cancer policy wellness benefit
  • aflac cancer screening benefit claim form
  • aflac cancer screening claim form
  • aflac cancer screening wellness benefit claim form
  • aflac cancer wellness benefit claim form
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.