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The UB-04 form is a standardized medical claim form used by institutional healthcare providers to submit billing information for services provided to patients. Its essentially a receipt used specifically by healthcare institutions.
$25 Aflac will pay $25 when a covered person incurs a charge for a physician visit. Services must be under the supervision of a physician. If the type of coverage for the policy is individual, the benefit is limited to three visits per calendar year, per policy.
Policy number. Policyholders name. Policyholders address. Date of injury or when symptoms first occurred. Definitions acronyms. ER visit. Surgery. Operative report - Must include the type of procedure or procedure code. My Claims.
HCFA 1500 (non-hospital bill). Motor vehicle accident (MVA). Authorization to obtain information (AU). (This allows Aflac to request additional documentation on your behalf.)
Contact your insurance company: Some insurance companies also provide pre-filled UB-04 forms for their members.
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The UB-04 uniform medical billing form is the standard claim form that institutional providers use, such as hospitals and community mental health care centers.
A hospital indemnity claim requires supporting documentation for review of benefits, itemized bills showing medical treatment dates and diagnosed conditions, hospital admission and discharge papers for inpatient hospital admission and confinement benefits, pharmacy receipts for prescription drug reimbursement, and a
Ub 04 Form Aflac is a standardized medical claim form used by Aflac for billing purposes. It includes detailed information about the patient, treatment, and costs incurred during a medical visit.

aflac physician statement form