If you are covered under an Aflac policy, it's important to know what your benefits are in the event of a critical illness. The Aflac Critical Illness Health Form can be used to document your coverage and ensure that you receive the best possible care should you become ill. Being familiar with this form can help reduce stress if you or a loved one is diagnosed with a critical illness. Download and print the form to have on hand for easy reference.
| Question | Answer |
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| Form Name | Aflac Critical Illness Health Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | aflac critical illness health screening form, aflac intensive care claim form, aflac critical illness form, aflac critical illness claim form pdf |
CONTINENTAL AMERICAN INSURANCE COMPANY
CRITICAL ILLNESS WELLNESS BENEFIT CLAIM FORM
INSTRUCTIONS
Please use black or blue ink only and print legibly when completing this form in its entirety. Keep a copy of the supporting documentation and this completed form for your records. Sign, date, and mail or fax the completed form to the address/number shown below.
Send all claims to: |
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Critical |
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Columbia, South |
Carolina 29202 |
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POLICYHOLDER/CLAIMANT'S |
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INFORMATION |
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POLICYHOLDER'S |
NAME |
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POLICY/CERTIFICATE NO. |
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DATE OF BIRTH |
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POLICYHOLDER'S |
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POLICYHOLDER'S |
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NO. |
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CLAIMANT'S |
NAME |
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CLAIMANT'S |
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POLICYHOLDER |
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HEAL TH SCREENING |
INFORMATION |
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WHICH HEALTH SCREENING |
TEST |
DID YOU HAVE PERFORMED: |
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MAMMOGRAPHY (date) |
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STRESS |
TEST ON A BICYCLE |
OR TREADMILL |
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FASTING BLOOD |
GLUCOSE TEST |
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BLOOD |
TEST FOR TRIGL YCERIDES |
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SERUM |
CHOLESTEROL |
TEST (HDL AND LDL) |
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BONE MARROW |
TESTING |
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BREAST |
ULTRASOUND |
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CA |
0 |
CA 125 (BLOOD |
TEST FOR OVARIAN CANCER) |
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CEA (BLOOD TEST FOR COLON CANCER) |
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CHEST |
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COLONOSCOPY |
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FLEXIBLE SIGMOIDOSCOPY |
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HEMOCULT |
STOOL ANALYSIS |
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THERMOGRAPHY |
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PAP SMEAR (date), |
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oPSA BLOOD TEST FOR PROSTATE CANCER 0 SERUM PROTEIN ELECTROPHORESIS MYELOMA 0 OTHER
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date M!!lil be provided |
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Physician Information' |
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Street Address |
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AUTHORIZATION
Any person who knowingly and with intent to defraud any insurance company, files a statement of claim containing any materially false, incomplete or misleading Information, is guilty of a crime.
I have checked the answers given by myself and they are correct. I AUTHORIZE any physician, medical practitioner, hospital, clinic, other medical or medically related facility, insurance or reinsuring company, consumer reporting agency, or employer having information available as to diagnosis, treatment and prognosis with respect to any physical or mental condition and/or treatment and any
Any information obtained will not be released by Continental American Insurance Company to any person or organization EXCEPT to reinsuring companies, or other persons or organizations performing business or legal services in connection with my claim, or as may otherwise lawfully required or as I may further authorize. I KNOW that I may request to receive a copy of this Authorization. I AGREE that a photographic copy of this Authorization shall be as valid as the original. I AGREE that this Authorization shall be valid for the duration of my claim.
Date: |
Claimant's Si nature: |
Date: |
CAFOO1 CIWSB
FRAUD WARNING NOTICES
For use with Claim Forms
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
ALASKA: A person who knowingly and with intent to injury, defraud or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.
ARIZONA: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
ARKANSAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
CAUFORNIA: For your protection California law requires the following to appear on this form:
Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
COLORADO: It is unlawful to knowingly provide false incomplete, or misleading facts or information to an ' insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
DELAWARE: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.
DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a st~tement of claim containing any false, incomplete, or rntsleadlnq information is guilty of a felony.
INDIANA: A person who knowingly and with intent to defraud an insurer files a statement of claim containing Any false, incomplete, or misleading information commits a felony.
KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading information concerning any fact material thereto com~its a fraudulent insurance act, which is a crime.
LOUISIANA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
MAINE: It is a crime to knowingly provide false incomplete or misleading information to an insur~nce company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
MARYLAND: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
MINNESOTA: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA
638:20.
NEW JERSEY: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
Rev 3/10 Expires 3/12
FRAUD WARNING NOTICES (CONT.)
For use with Claim Forms
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
NEW MEXICO: ANY PERSONWHO KNOWINGLY PRESENTSA FALSEOR FRAUDULENTCLAIM FORPAYMENT OFA LOSSOR BENEFITOR KNOWINGLYPRESENTSFALSE INFORMATIONIN AN APPLICATIONFORINSURANCEIS GUILTYOFA CRIMEAND MAYBE SUBJECTTO CIVIL FINES AND CRIMINAL PENALTIES.
NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
OKLAHOMA: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
OREGON: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
PUERTO RICO: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances are present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
TENNESSEE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
TEXAS: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
VIRGINIA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
RHODE ISLAND AND WEST VIRGINIA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Rev 3/10 Expires 3/12