Allstate wellness claim form 2026

1. Click ‘Get Form’ to open the Allstate Wellness Claim Form in our editor.
2. Begin by filling in the 'POLICYHOLDER / CERTIFICATEHOLDER' section. Enter the insured's name, gender, policy number(s), and social security number.
3. Provide the patient's date of birth and contact information, including home number and email address.
4. In the 'WELLNESS SCREENINGS' section, check all applicable boxes for preventative tests or vaccinations received. Ensure you attach any relevant documentation.
5. If applicable, complete the 'ASSIGNMENT OF BENEFITS FOR WELLNESS COVERAGE' section by providing the name and address of the person to whom benefits should be sent.
6. Sign and date the authorization statement at the bottom of the form to allow access to your medical records as needed for processing your claim.
7. Finally, review all entered information for accuracy before submitting your claim via mail or fax as indicated on the form.

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