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The document is a Cancer Screening Wellness Benefit Claim Form provided by Aflac, outlining the process for policyholders to claim their annual wellness benefit. It includes instructions on completing the form, specifies that only one wellness benefit can be claimed per covered person each year, and emphasizes the need to submit separate claims for other cancer-related benefits. The form requires personal information from the policyholder and patient, details of wellness exams performed, and must be mailed to Aflac's claims department without additional documentation.

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