Hospital Policy Claim – Accident

Required forms (click on each form to open and print):

After you have downloaded or printed the above forms just print this page and follow these instructions. For faster service fax directly to our claims department using the Claims Department fax cover sheet. If you mail anything, please keep copies of everything you mail until your claim is complete.

It is important to follow these instructions completely. Failure to do so will result in a delay of the processing of your claim.

1. You (or the patient) need to personally complete Section A. Be sure to complete all sections.

2. Section B needs to be completed in full by the physician who treated you. Please be sure no sections are left uncompleted unless they do not apply.

3. Section C and D do not apply to your claim unless you are also claiming from an AFLAC Short Term Disability policy, however you must sign the form at the bottom of page 2.

4. Please be sure to include the following backup documentation that applies to your treatment.

Itemized hospital bill (if confined) [Click here to see a sample]

Operative Report (if surgery was required)

Ambulance bill

Police Report (if you were injured in an auto accident)

Include the First Report of Injury from your employer if this claim is for a Workers Compensation injury

This type of supporting information is very important because the claim cannot be processed without it.

After you have sent your claim please deal directly with AFLAC Claims Department by calling 1-800-992-3522 from 8 a.m. to 6 p.m. Monday through Friday. Please have your policy number ready so you can be assisted promptly. Also, if you have any questions regarding your claim or if you simply want personal assistance please feel free to call me at 561-776-0098.

Reminder checklist – Please be sure you have you completed or provided the following:

· Have you completed Section A and the Authorization to Obtain

Information?

· Have you signed at the end of Section D?

· Has your physician completed Section B?

· If you were confined in a hospital have you included a copy of the Itemized

hospital bill? This bill must show a room charge in order for

benefits to be paid. Please click the following link to view a sample:

[Sample Itemized Hospital Bill] A copy of this bill should be requested

from the hospital billing or records department.

· If surgery was required have you included a copy of the Operative

Report? This should be requested from your surgeon.

· If you required an ambulance have you included a copy of the ambulance

bill?

· If this injury was caused by an auto accident have you included a copy of

the police report?

· If this claim is for a Workers Compensation injury, have you included

a copy of the First Report of Injury from you employer?

· Have you included your policy number? If you do not have your

policy number, please call 800-992-3522 to be provided with it. It is

important to remember that each policy has a separate policy number.

· Before faxing to our Claims Department have you included your

information on the fax cover sheet?

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