Aflac Wellness Forms 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.

QuestionAnswer
Form NameAflac Wellness Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesaflac accident wellness claim form, aflac wellness claim form printable, aflac wellness claim form, aflac wellness claims form

Form Preview Example

DUCK

Accident/Hospital Indemnity Wellness Benefit Claim Form

If you are interested in filing your claim online, register using aflac.com/smartclaim.

Benefits of filing your claim online include faster claim processing time and receiving claim communications by email.

Please read all instructions.

Failure to follow these instructions could delay the processing of your claim.

Your Aflac policy provides a Wellness Benefit. To receive your Wellness Benefit, complete the form by following the instructions provided. Please check your policy for specific details on this benefit.

Do not include receipts, statements or other claim documentation with this form.

Do not write on form except as instructed.

Please sign, date and mail or fax the completed form to the Aflac address/fax number shown below.

Please use black or blue ink only and print legibly when completing this form in its entirety.

Mark only wellness exam box(es) for test(s) that you had performed.

Failure to complete all sections may result in a delay in processing this claim.

Some types of tests and/or treatment listed may not be covered by your policy.

Please keep a copy of this completed form for your records. Please print a separate form for each additional family member or call 1-800-99-AFLAC (1-800-992-3522) to request additional forms. Claims for all other benefits covered under this policy must be filed separately using the claim forms available at aflac.com or by calling 1-800-99-AFLAC (1-800-992-3522).

CW 061999Page 1 of 202/14

American Family Life Assurance Company of Columbus (Aflac)

ATTN: Claims Department • 1932 Wynnton Road • Columbus, GA 31999

For information or to check claim status, visit aflac.com or call 1-800-99-AFLAC (1-800-992-3522)

Claims may be faxed to 1-877-44-AFLAC (1-877-442-3522)

Accident/Hospital Indemnity Wellness Benefit Claim Form

Policy Number: Policyholder Information:

Last Name

All Fields are required.

Suffix

 

First Name

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yy)

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

Home Address

Telephone Number where we can reach you

 

 

 

-

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CityState Zip Code

Check box if this is permanent address change.

Patient Information:

Last Name

First Name

Date of Birth (mm/dd/yy)

/

/

Sex:

Male

Female

Relationship:

Primary Policyholder

Treatment and Physician Information

M M D D Y Y Y Y

Treatment

Date:

Spouse

Dependent Child

M M D D Y Y Y Y

Mammogram

Date:

M M D D Y Y Y Y

Pap Smear

Date:

Annual Physical

Ultrasound

PSA (blood test for prostate cancer)

Pap Smear

Physician’s Name

Blood Screening

Immunizations

Eye Exam

Mammogram

Physician’s

Phone

Number:

Dental Exam

Flexible Sigmoidoscopy

 

 

 

-

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s Street Address

Physician’s City

State:

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

The Provider listed above is authorized to validate the information I have provided.

POLICYHOLDER/PATIENT SIGNATURE

FAMILY RELATIONSHIP, IF NOT POLICYHOLDER

DATE

CW 061999

Page 2 of 2

02/14

American Family Life Assurance Company of Columbus (Aflac)

ATTN: Claims Department • 1932 Wynnton Road • Columbus, GA 31999

For information or to check claim status, visit aflac.com or call 1-800-99-AFLAC (1-800-992-3522)

Claims may be faxed to 1-877-44-AFLAC (1-877-442-3522)

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