Aflac Wellness Form – Fill Out and Use This PDF

Aflac Wellness Formula is a program that helps you get healthy. It provides access to information, resources and guidance on how to live a healthier lifestyle.

The best place to access and use this form is here. Our simple PDF tool will allow you to have your document within minutes. Any system you select, whether a PC, laptop, smartphone, or tablet, can be used.

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Aflac Wellness Form PDF Details

Aflac has always been a trusted name in supplemental insurance. Now, they are offering another way to help you stay healthy – the Aflac Wellness Form. This form helps you keep track of your health history and current health conditions, making it easy to submit information to your insurance company. Plus, Aflac makes it easy to find a doctor and get preventive care discounts. If you’re looking for an easy way to keep your health records organized, the Aflac Wellness Form is a great option.

Below is the data in regards to the form you were looking for to complete. It can tell you the time it may need to finish aflac wellness form, what fields you will need to fill in, and so forth.

Question	Answer
Form Name	Aflac Wellness Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	62
Avg. time to fill out	12 min 43 sec
Other names	aflac wellness claims form, aflac hospital wellness claim form, aflac accident wellness claim form, aflac wellness form online

12

Form Preview Example

Post Office Box 84075 *Columbus, GA. 31993 Phone (800) 433-3036 *

Fax (866) 849-2970 groupclaimfiling@aflac.com

WELLNESS AND HEALTH SCREENING CLAIM FORM

Failure to complete all sections may result in delayed processing of this claim.

Review your policy for specific benefits covered under your plan.

AUTHORIZATION

Any person who knowingly and with intent to defraud any insurance company, files a statement of claim containing anymaterially false, incomplete or misleading information, is guilty of a crime.

Ihave 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 company, consumer report agency, or employer having information available asto diagnosis, treatment and prognosiswith respect toany physical or mental condition and/or treatment and any non-medical information for me, to give to Continental American Insurance Company or itslegal representative, any and all such information. Thisinformation isto include, but isnot limited to information pertaining to diagnosis, care or treatment for psychiatric disorder, drug or alcohol abuse, treatment or prescriptions, testing and/or treatment of HIV (AIDS virus) and/or other sexually transmitted diseases, including case history and medical antecedents. I UNDERSTAND the information obtained by use of the Authorization will be used by Continental American Insurance Company to determine eligibility for benefits under an existing certificate. Any information obtained will not be released by Continental America Insurance Company to any person or organization EXCEPT to re-insuring companies, or other person or organization performing businessor legal servicesin connection with any claim, or asmay otherwise lawfully required or asI may further authorize. I KNOW that I may request to receive a copy of thisAuthorization. I AGREE that thisauthorization shall be valid for the duration of my claim.

Policyholder’s Signature:Date:Claimant’s Signature:Date:

POLICYHOLDER/PATIENT INFORMATION

EMPLOYER’S NAME				POLICYHOLDER’S EMAIL ADDRESS

MAJOR MEDICAL INSURANCE PROVIDER				MAJOR MEDICAL INSURANCE ID#

POLICYHOLDER’S NAME		POLICY NO		SSN/ EMPLOYEE ID		DATE OF BIRTH			GENDER

POLICYHOLDER’S ADDRESS			CITY	STATE		ZIP CODE		POLICYHOLDER’S	PHONE NUMBER
CHECK BOX IF THIS IS A PERMANENT	ADDRESS CHANGE
PATIENT’S NAME			RELATIONSHIP TO THE POLICYHOLDER		PATIENT’S DATE OF BIRTH					PATIENT’S GENDER

*By providing your e-mail address above, you consent to the use of electronic transactions in connection with your CAIC policies, contracts, and/or accounts to the extent available permitted by law (which may include, but not limited to: invoices, claim correspondence, contracts, surveys, and other materials that CAIC is, or may be, legally required to deliver to you).

HEALTH SCREENING INFORMATION

DATE HEALTH SCREENING TEST WAS PERFORMED:

WHICH HEALTH SCREENING TEST DID YOU HAVE PERFORMED:

Annual Physical

Biometric Screening

Blood Screening

Blood Test for Triglycerides

Bone Marrow Testing

Breast Ultrasound

CA 125

CA 15-3

CEA

Chest X-Ray

Colonoscopy

DNA Stool Analysis	Non-Diagnostic Vascular Screening
Eye Examinations	Pap Smears
Fasting Blood Glucose	PSA Test
Flexible Sigmoidoscopy	Serum Cholesterol Test
Hemoccult Stool Analysis	Serum Protein
HIV (Human Immunodefiency)	Skin Cancer Screening
HPV (Human Papillomavirus)	Spinal CT Screening
HSN Strains	Stress Test on Bicycle or Treadmill
Human Coronavirus Testing	Thermography
Immunizations	Ultrasounds
Mammograms	Urinalysis

PHYSICIAN INFORMATION

NAME

ADDRESS

TELEPHONE NUMBER

CITY

STATE

ZIP CODE

How to Edit Aflac Wellness Form Online for Free

It's easy to prepare the wellness claim form using this PDF editor. These steps will let you immediately prepare your document.

Step 1: Click on the button "Get Form Here".

Step 2: After you have entered your wellness claim edit page, you will notice all actions it is possible to use concerning your file in the upper menu.

The next parts are what you are going to fill out to obtain the finished PDF form.

stage 1 to completing aflac wellness benefit form

Please submit your details inside the section MAJOR MEDICAL INSURANCE PROVIDER, MAJOR MEDICAL INSURANCE ID#, POLICYHOLDER, S NAME, POLICY NO, S, SN EMPLOYEE ID, DATE OF BIRTH, GENDER, POLICYHOLDER, S ADDRESS, CITY, STATE, ZIP CODE, POLICYHOLDER, S PHONE NUMBER, CHECK BOX IF THIS IS A PERMANENT, RELATIONSHIP TO THE POLICYHOLDER, and PATIENT, S DATE OF BIRTH.

Entering details in aflac wellness benefit form part 2

Make sure you point out the vital information from the Annual Physical Biometric, NAME, ADDRESS, DNA Stool Analysis Eye, Non, Diagnostic Vascular Screening, PHYSICIAN INFORMATION TELEPHONE, CITY, STATE, and ZIP CODE area.

aflac wellness benefit form Annual Physical Biometric, NAME, ADDRESS, DNA Stool Analysis Eye, Non-Diagnostic Vascular Screening, PHYSICIAN INFORMATION TELEPHONE, CITY, STATE, and ZIP CODE blanks to fill

Step 3: Press the "Done" button. Now you may transfer your PDF form to your electronic device. Aside from that, it is possible to send it by means of email.

Step 4: It's possible to make copies of your document torefrain from different upcoming complications. You need not worry, we don't reveal or monitor your details.

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