Specified Health Event Claim Form – Fill Out and Use This PDF

SPECIFIED EVENT/LUMP SUM CRITICAL ILLNESS EVENT CLAIM FORM

Thank you for trusting Aflac with your Specified Event/Lump Sum Critical Illness Event needs.

If you are interested in filing your claim online or uploading documentation on an existing claim, register using aflac.com/smartclaim.

To prevent delays, please provide documentation from your healthcare provider to support this claim. If you have additional bills or medical documentation that relates to this diagnosis other than the documentation defined, please submit them for review of additional benefits.

Service related items can be obtained directly from the patient’s healthcare provider(s) by requesting a UB04 hospital bill or HCFA 1500 non-hospital bill.

Failure to complete all sections may result in a delay in processing this claim. Disclaimer: Some of the services listed may not be covered by your policy.

*Policy Number:

Policyholder Information: This * denotes a required field.

*Last Name

Suffix

*First Name

MI

*Date of Birth (mm/dd/yy)

Telephone Number where we can reach you

*City

*State

*Zip Code

-

Check box if this is a permanent address change.

Patient Information:

*Last Name

*First Name

*Date of Birth (mm/dd/yy)

• Please indicate the condition the patient is filing for below and submit the appropriate medical documentation:

Coma - Documentation from the health care provider indicating the duration of the coma and the ranking on the coma scale.

Burn - Documentation showing the total percentage of the body with third degree burns.

Paralysis - Documentation from the health care provider of complete and total loss of use of two or more limbs, including the duration of paralysis.

Heart attack - Documentation of the electrocardiographic findings or clinical findings together with test results of blood enzymes diagnosing a heart attack.

Stroke - Documentation of a neurological deficit with complete or partial function loss for more than 24 hours.

End stage renal failure - Documentation of a diagnosis of permanent and irreversible kidney failure.

Persistent vegetative state - Statements from two physicians indicating cognitive function has been substantially impaired and there is no reasonable expectation that the patient will regain cognitive function.

Sudden cardiac arrest - Documentation or the discharge summary indicating the diagnosis.

Coronary artery bypass graft surgery - Documentation from the health care provider indicating open-heart surgery was performed to correct the narrowing or blockage of one or more coronary arteries with bypass grafts.

Major human organ transplant - Documentation from the health care provider indicating the covered person has received, as a result of surgical transplant, one or more of the following human organs: kidney, liver, heart, lung, or pancreas.

Heart surgery - Documentation from the health care provider indicating the type of heart surgery performed. Bone marrow transplant - Documentation from the health care provider indicating a bone marrow transplant was performed.

Internal cancer - The initial pathology report or exam that initially diagnosed internal cancer.

Noninvasive cancer - The initial pathology report or exam that initially diagnosed noninvasive cancer. Skin cancer - The initial pathology report or exam that initially diagnosed skin cancer.

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)

S00223 FL

Page 1 of 2

10/17

If you have additional bills or medical documentation that relates to this diagnosis other than the documentation defined, please submit them for review of additional benefits.

*Policy Number:

Policyholder Information:

*Last Name

Suffix

*First Name

MI

*Date of Birth (mm/dd/yy)

Patient Information:

*Last Name

*First Name

*Date of Birth (mm/dd/yy)

•

Symptoms first occurred on:

/

/

First date of treatment for this condition:

/

/

•

Was death a result of this condition?

No

Yes

(If yes, please submit a copy of the death certificate and legal

documents verifying the person authorized to handle the affairs of the deceased).

•

Was the patient injured in a motor vehicle accident?

No

Yes

(If yes, please submit a copy of the Police Report.)

•

Was the patient confined to the hospital as a result of this condition?

No

Yes (If yes, please submit the itemized

hospital bill, UB04, or HCFA 1500.)

Hospital name

City

State

•

Was the patient confined to the intensive care unit as a result of this condition?

No

Yes

(If yes, please submit the

itemized hospital bill, UB04, or HCFA 1500.)

•Please provide the name, address and phone number of the patient’s primary treating physician.

Name:			Phone Number:
Address:

•Was the patient treated by any other physicians for this condition? No Yes If yes, physician’s name(s):

Phone Number(s): Address:

• Was the patient transported by an ambulance as a result of this condition?	No	Yes (If yes, please submit the
ambulance bill.)

•Transportation/Lodging Information: Did you incur charges for transportation or lodging? No Yes (If yes, please submit the hotel receipts and mileage information.)

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.

POLICYHOLDER/PATIENT SIGNATURE

FAMILY RELATIONSHIP, IF NOT POLICYHOLDER

DATE

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)

S00223 FL

Page 2 of 2

10/17