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Click ‘Get Form’ to open the Aflac Hospital Indemnity Claim Form in the editor.
Begin by filling out the Policyholder Information section. Enter your policy number, last name, first name, middle initial, date of birth, and telephone number. Ensure all fields marked with an asterisk (*) are completed.
Next, provide your home address including city, state, and zip code. If this is a permanent address change, check the corresponding box.
Proceed to the Patient Information section. Fill in the patient's last name, first name, date of birth, sex, and relationship to the policyholder.
Complete the Hospital Indemnity Checklist by answering questions regarding treatment due to injury or sickness. Provide details as required for each question.
Finally, review all sections for completeness before signing at the bottom of the form. Ensure you have included any necessary documentation as indicated.
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How to fill out the Aflac Initial Disability Claim Form? Gather all necessary personal and policy information. Complete the required fields accurately. Attach all relevant documentation to support your claim. Review the form for completeness before submission. Submit the form through the designated channels.
How to fill out Aflac initial disability claim form?
Aflac pays you cash benefits directly (unless assigned), which can be used for any of these services: Ambulance Rates. Aflac can help pay for those additional costs on top of treating the injury. Intensive Care Costs. Therapy Charges. Rehabilitation Costs. Major Diagnostic Test Exam Fees. Family Support Benefits.
What is a UB-04 form for Aflac?
Forms Needed From Doctor for Aflac claim The UB-04 uniform billing form is the standard claim form that any institutional provider can use for the billing of medical and mental health claims. Its printed with red ink on white standard paper.
What is a UB04 form used for?
Your healthcare provider - You can request a sample UB-04 form from your healthcare provider. They may have a blank copy of the form that you can use as a reference. Commercial printing companies - Many companies specialize in printing medical forms, including the blank UB-04 form.
How do I obtain an UB-04 form?
➜ Hospitals General hospitals, childrens hospitals, and specialty hospitals all use the UB-04 form to bill for inpatient and outpatient services, including surgeries, diagnostic tests, and other medical treatments.
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AFLAC Forms
University Benefits AFLAC - Accident or Injury Claim Form AFLAC - Accident Wellness Form AFLAC - Cancer Claim Form AFLAC - Cancer Wellness Form AFLAC
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