Aflac Benefit Services Request for Reimbursement Form 2025

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The document is an Aflac Benefit Services Request for Reimbursement Form, which outlines the process for employees to request reimbursement for eligible medical and dependent care expenses from their Flexible Spending Accounts (FSA). It includes instructions on completing the form, required documentation, and submission guidelines. The form requires personal information, details of expenses, and signatures to certify the claims. Additionally, it provides helpful tips for filing claims and lists examples of eligible and ineligible expenses.

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

Where do I get Aflac claim forms?

A UB04 document includes all information required to get your claim expedited the fastest. ACCIDENT/INJURY CLAIM instructions. Accident Claim Form Authorization to Obtain Information. SHORT-TERM DISABILITY CLAIM.

How do I get reimbursed from Aflac?

Additional reimbursement forms can be obtained at aflac.com or via the IVR at 1-877-353-9487. Fax your completed Flex One Request for Reimbursement Form and all documentation to: 1-877-FLEX-CLM (1-877-353-9256). Please allow 48 hours for the receipt of your faxed form before calling to inquire about your reimbursement.

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).

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.

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.

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What is a UB 04 form Aflac?

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

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.

Aflac Benefit Services Request for Reimbursement Form 2025

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How to edit Aflac Benefit Services Request for Reimbursement Form in PDF format online

See more Aflac Benefit Services Request for Reimbursement Form versions

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Got questions?

Where do I get Aflac claim forms?

How do I get reimbursed from Aflac?

What is needed for an Aflac cancer claim?

How far back will Aflac pay?

Is there a deadline to file a claim with Aflac?

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What is a UB 04 form Aflac?

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

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