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See more hospital confinement claim form versions

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Versions Form popularity Fillable & printable
FSL Hospital Confinement Indemnity (GAP) Claim Form 2019 4.9 Satisfied (35 Votes)
FSL Hospital Confinement Indemnity (GAP) Claim Form 2017 4.3 Satisfied (98 Votes)
FSL Hospital Confinement Indemnity (GAP) Claim Form 2014 4.4 Satisfied (125 Votes)
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The UB04 claim form is used to submit claims for inpatient and outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics, chronic dialysis and Adult Day Health Care).
On the other hand, the HCFA-1500 (CMS 1500) is a medical claim form employed by individual doctors practices, nurses, and professionals, including therapists, chiropractors, and out-patient clinics.
Use these instructions for completing this form. The Form HCFA-1500 has space for physicians and suppliers to provide information on other health insurance.
Please print a separate form for each additional family member or call 1-800-99-AFLAC (1-800-992-3522) to request additional forms. Claims for all other benefits covered under this policy must be filed separately using the claim forms available at or by calling 1-800-99-AFLAC (1-800-992-3522).
How long do I have to file a claim? A. There is a one-year timely filing provision in your certificate. Please review the provision and call us with any questions.
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People also ask

UB04 (itemized hospital bill). ER report or operative report. (Please obtain the supporting documents for the corresponding benefit.) (Please include at least three pieces of identifying information.)
In order to purchase claim forms, you should contact the U.S. Government Printing Office at 1-866-512-1800, local printing companies in your area, and/or office supply stores. Each of the vendors above sells the CMS-1500 claim form in its various configurations (single part, multi-part, continuous feed, laser, etc).
Hospital indemnity insurance (also known as hospital confinement insurance or simply hospital insurance) is supplemental medical insurance coverage that pays benefits if you are hospitalized.
(This allows Aflac to request additional documentation on your behalf.) Emergency room (ER). Itemized hospital bill (IHB). UB04 (itemized hospital bill).
Send to: Phone:(800) 433-3036. Fax:(866) 849-2970. Email:

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