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The document is a Physician’s Visit Benefit Claim Form from Aflac, outlining the process for filing a claim for benefits related to physician visits. It provides instructions for online claim submission, eligibility verification, and details required information such as policyholder and patient data. The form emphasizes the importance of completing all sections accurately to avoid processing delays and includes a warning about fraudulent claims.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (149 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Is there a deadline to file a claim with Aflac?

Q. How long do I have to file a claim? A. There is a one-year timely filing provision in your certificate.

How long do I have to have Aflac before I can file a claim?

Aflac will not pay benefits for an illness, disease, infection, or disorder that is diagnosed or treated by a Physician within the first 30 days after the Effective Date of coverage, unless the resulting disability begins more than 12 months after the Effective Date of coverage.

How far back will Aflac pay?

We will pay the amount shown when, because of a covered accident, you are injured and those injuries cause confinement to a hospital for at least 24 hours within 90 days after the accident date. The maximum period for which you can collect the Hospital Confinement Benefit for the same injury is 365 days.

What is needed for an Aflac cancer claim?

Please submit the pathology report used in the diagnosis of a malignant cancer, the claimants birth certificate, and any itemized medical bills with the diagnosis and procedure codes, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form).

Where do I get Aflac claim forms?

1If all documentation is not available upon initial claim filing, you may upload the documents later by clicking Upload Documents on the mobile app or MyClaims on desktop. Register or Log in: Go to aflac.com/myaflac or download the Aflac SmartClaim Mobile app from the App Store or Google Play Store. One Day Pay*.

How do I upload documents to an Aflac claim?

HCFA 1500 (non-hospital bill). Motor vehicle accident (MVA). Authorization to obtain information (AU). (This allows Aflac to request additional documentation on your behalf.)

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