S 2029 Form PDF Details

In an era where precise documentation is key to ensuring smooth insurance claim processes, understanding the intricacies of forms like the S 2029 becomes indispensable. Crafted for policyholders under the American Family Life Assurance Company of Columbus, commonly known as AFLAC, this form is designed to facilitate the submission of claims, whether they relate to accidents, disabilities, intensive care, or cancer policies among others. It serves as a vital communication tool between the claimant and AFLAC, necessitating detailed completion for a hassle-free claim experience. The form is segmented into various sections, each requiring specific information about the patient, the policyholder, and the nature of the claim itself, accompanied by a physician's statement for a comprehensive understanding of the medical scenario. At the heart of it, the S 2029 form emphasizes transparency and accuracy in reporting the claim details, underlined by the stern warning against fraudulent claims. Moreover, the form underscores the importance of consent, with a section dedicated to authorizing AFLAC or its representatives access to essential medical records, thereby balancing the need for information with the privacy rights of the individual. This delicate interplay of providing accurate, detailed information while adhering to legal and ethical standards defines the essence of the S 2029 form and its role in the broader context of insurance claims.

QuestionAnswer
Form NameS 2029 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesaflac cancer claim forms to print, aflac cancer claim forms print, aflac claim forms cancer continuing to print, skin cancer aflac claim forms print

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AMERICAN FAMILY LIFE ASSURANCE COMPANY OF COLUMBUS (AFLAC)

ATTN: CLAIMS DEPT., WORLDWIDE HEADQUARTERS: 1932 WYNNTON ROAD, COLUMBUS, GA 31999-7251

FOR INFORMATION, CALL TOLL-FREE 1-800-99-AFLAC (1-800-992-3522) OR VISIT OUR WEBSITE AT WWW.AFLAC.COM

TOLL FREE FAX NUMBER 1-877-44AFLAC (1-877-442-3522)

PATIENT’S CLAIM FORM - Please fully complete the top half.

FOR ASSOCIATE USE ONLY:

Check the appropriate box:

Send the insured's check to the agent for delivery.

Contact the associate only if additional information is needed to complete processing of this claim.

Writing #:

 

Name:

Address:

PATIENT’S INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICYHOLDER’S INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST

FIRST

 

 

 

MIDDLE

 

 

 

SEX

LAST

 

FIRST

 

MIDDLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS - STREET & NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS - STREET & NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE/ZIP CODE

CITY

 

 

 

 

 

 

 

STATE/ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTH DATE

 

 

MARITAL STATUS

 

 

 

 

 

 

 

 

 

 

PATIENT’S SOCIAL SECURITY NUMBER

 

(AREA CODE & PHONE NO.)

 

 

 

 

 

 

 

 

 

SINGLE

 

MARRIED OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RELATIONSHIP TO POLICYHOLDER

 

 

SELF

 

 

SPOUSE

 

 

CHILD

 

 

 

 

 

 

 

 

 

 

 

 

STEPCHILD

 

OTHER:

 

 

 

 

 

 

 

 

 

 

 

 

 

IS PATIENT:

 

EMPLOYED

PART-TIME STUDENT

 

FULL-TIME STUDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF CLAIM

CANCER

POLICY NO(S)

INTENSIVE CARE

POLICY NO(S)

ACC/DISABILITY

POLICY NO(S)

HOSPITAL INDEMNITY

POLICY NO(S)

BRIEFLY DESCRIBE NATURE OF ILLNESS OR HOW INJURY OCCURRED:

IF ACCIDENT, LOCATION:

 

 

 

SPECIFIED MAJOR

POLICY NO(S)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EVENT / OTHER

 

 

 

 

 

 

 

 

 

 

 

DATE:

TIME:

AM/PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTACH HOSPITAL BILL IF APPLICABLE

 

 

 

 

 

 

 

DO NOT WRITE ANYTHING BELOW THIS LINE EXCEPT PATIENT’S SIGNATURE. DOING SO MAY RESULT IN THE DELAY OF YOUR CLAIM.

 

 

 

 

 

 

 

 

 

AUTHORIZATION TO RELEASE INFORMATION

 

 

 

 

 

 

 

 

 

 

(TO BE COMPLETED BY AFLAC CLAIMS DEPARTMENT)

 

 

 

 

TO:

 

 

RE: Patient:

 

 

 

 

 

 

 

 

 

 

 

Patient Hospital #:

 

 

 

 

 

 

 

 

 

 

Patient’s SS #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TREATMENT DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISCHARGE SUMMARY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HISTORY & PHYSICAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OPERATIVE REPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATHOLOGY REPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN’S OFFICE NOTES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BLOOD ALCOHOL TEST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

URINE DRUG SCREEN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

I hereby request and authorize you to furnish to AMERICAN FAMILY LIFE ASSURANCE COMPANY OF COLUMBUS (AFLAC) or its representative any and all medical information concerning any illness or injury I may have suffered, including HIV testing, and the diagnosis and treatment of communicable diseases, ARC, AIDS, chemical dependency or psychiatric illness.

 

 

TO BE COMPLETED BY THE PATIENT

Persons signing may receive a copy of this authorization. Any copy of this authorization shall have the same authority as the original.

 

 

 

 

 

 

SIGNATURE OF PATIENT (IF MINOR, PARENT MUST SIGN)

 

 

DATE

IF SIGNED IN BEHALF OF ANOTHER, RELATIONSHIP

 

 

 

 

(ONLY IF PATIENT IS UNABLE TO SIGN)

Expires six months from date written above unless indicated otherwise or revoked earlier.

S-2029

08/99

PHYSICIAN’S STATEMENT

AMERICAN FAMILY LIFE ASSURANCE COMPANY OF COLUMBUS (AFLAC)

ATTN: CLAIMS DEPT., WORLDWIDE HEADQUARTERS: 1932 WYNNTON ROAD, COLUMBUS, GA 31999-7251 For information call TOLL-FREE 1-800-99-AFLAC (1-800-992-3522) or visit our website at www.AFLAC.com TOLL FREE FAX NUMBER 1-877-44AFLAC (1-877-442-3522)

 

 

 

 

 

 

 

 

TO BE COMPLETED IN FULL BY ATTENDING PHYSICIAN

 

 

 

 

 

 

 

PATIENT’S INFORMATION

 

 

 

 

 

 

 

 

 

 

POLICYHOLDER’S INFORMATION

 

LAST

FIRST

MIDDLE

 

 

SEX

LAST

 

 

 

 

FIRST

 

 

 

MIDDLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS-STREET & NUMBER

 

 

 

 

 

 

 

ADDRESS - STREET & NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

STATE/ZIP CODE

 

CITY

 

 

 

 

 

 

 

 

 

STATE/ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTH DATE

 

STATUS

 

 

 

 

 

 

 

PATIENT’S RELATIONSHIP TO POLICYHOLDER:

 

 

PHONE

 

 

 

SINGLE

MARRIED

OTHER:

 

 

SELF

 

SPOUSE

CHILD

 

STEPCHILD

 

OTHER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICY NUMBER(S):

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.

DIAGNOSIS

 

 

 

 

IF INJURY, GIVE DATE AND PLACE OF INCIDENT.

1.

 

ICD

 

 

 

2.

 

ICD

 

 

IF LOSS IS DUE TO ACCIDENTAL INJURY, EXPLAIN HOW ACCIDENT OCCURRED.

LIST ANY CHRONIC ILLNESS OR DISEASE

 

 

 

 

 

1.

 

ONSET DATE

 

 

 

2.

 

ONSET DATE

 

 

 

3.

 

ONSET DATE

 

 

 

IF AUTO ACCIDENT, WAS PATIENT

DRIVER PASSENGER UNKNOWN

IS THIS ACCIDENT/ILLNESS COVERED BY WORKER’S COMPENSATION?

YESNO

IS THIS ACCIDENT/ILLNESS COVERED BY MEDICAID / STATE AID?

YESNO

1.

DATE SYMPTOMS FIRST OCCURRED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE PATIENT FIRST CONSULTED YOU FOR THIS CONDITION

 

 

 

2.

HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION?

 

 

NO

 

 

YES (IF YES, STATE WHEN AND DESCRIBE)

 

 

 

 

 

 

 

3.

REFERRING PHYSICIAN (NAME/ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

WAS PATIENT HOSPITALIZED FOR THIS CONDITION?

 

 

 

 

NO

 

YES IF YES, HAVE CLAIMANT ATTACH A COPY OF THE ITEMIZED HOSPITAL BILLING WHEN SUBMITTING CLAIM FOR

 

REVIEW .

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

DATE PATIENT LAST EXAMINED BY YOU

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FREQUENCY OF VISITS

 

WEEKLY

 

 

 

MONTHLY

 

OTHER

6.

IS PATIENT UNABLE TO PERFORM JOB DUTIES?

 

 

NO

 

 

 

 

 

 

YES (IF YES, GIVE DATES)

 

 

 

 

 

 

 

 

 

 

 

 

7.

WHAT SPECIFIC JOB DUTIES IS PATIENT UNABLE TO PERFORM?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

IS PATIENT

 

AMBULATORY

 

BED CONFINED

 

 

 

 

HOUSE CONFINED

 

 

HOSPITAL CONFINED

 

 

OTHER

 

 

 

9.

IF RETIRED, WHICH ACTIVITIES OF DAILY LIVING (ADLs) IS PATIENT UNABLE TO PERFORM?

 

 

 

 

 

 

 

 

 

 

 

 

 

DATES OF SERVICE

PLACE OF

SERVICE

IN/OP

PROCEDURE DESCRIPTION

# UNITS

CODE

CPT

HCPCS/RVS

DIAGNOSIS CODE ICD.0

CHARGE

Date

 

SIGNED

Name of Attending Physician (Please Print)

Tax ID or Social Security Number

(Street Address)

(City or Town)

(State)

(Zip Code)

(Area Code - Phone)

I hereby request and authorize you to furnish to AMERICAN FAMILY LIFE ASSURANCE COMPANY OF COLUMBUS (AFLAC) or its representative any and all medical information concerning any illness or injury I may have suffered including HIV testing and the diagnosis and treatment of communicable diseases, ARC, AIDS, chemical dependency or psychiatric illness.

Persons signing may receive a copy of this authorization. Any copy of this authorization shall have the same authority as the original.

SIGNATURE OF PATIENT (IF MINOR, PARENT MUST SIGN)

DATE

 

 

( Expires six months from this date unless indicated or revoked earlier.)

If signed on behalf of another, relationship

 

 

(Only if patient is unable to sign)

S-2029

08/99

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