CANCER 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).
DUCK
American Family Life Assurance Company of Columbus (Aflac)
ATTN: Claims Department • 1932 Wynnton Road • Columbus, GA 31999
For information, call 1-800-99-AFLAC (1-800-992-3522) or visit aflac.com
To check claim status Aflac’s Interactive Voice Response is available 24/7 at 1-877-353-9487 or visit aflac.com/smartclaim.
Claims may be faxed to 1-877-44-AFLAC (1-877-442-3522)
CW06917CA CO Page 1 of 2 02/14
Policyholder Information:
Policy Number:
Patient Information:
POLICYHOLDER/PATIENT SIGNATURE FAMILY RELATIONSHIP, IF NOT POLICYHOLDER DATE
Check box if this is permanent address change.
All Fields are required.
CANCER WELLNESS BENEFIT CLAIM FORM
Cervical Cancer Screening
Last Name Suffix First Name MI
Date of Birth (mm/dd/yy) Telephone Number where we can reach you
Home Address
City State Zip Code
Last Name First Name Date of Birth (mm/dd/yy)
Sex: Male Female
Relationship: Primary Policyholder Spouse Dependent Child
Physician’s Street Address
Physician’s City State: Zip:
Physician’s Name
Physician’s
Phone
Number:
M M D D Y Y Y YM M D D Y Y Y Y
American Family Life Assurance Company of Columbus (Aflac)
ATTN: Claims Department • 1932 Wynnton Road • Columbus, GA 31999
For information, call 1-800-99-AFLAC (1-800-992-3522) or visit aflac.com
To check claim status Aflac’s Interactive Voice Response is available 24/7 at 1-877-353-9487 or visit aflac.com/smartclaim.
Claims may be faxed to 1-877-44-AFLAC (1-877-442-3522)
CW06917CA CO Page 2 of 2 02/14
Testicular Ultrasound
Hemocult Stool Specimen
CEA (blood test for colon cancer)
CA 125 (blood test for ovarian cancer)
Mammogram
CA153
Thermography
PSA (blood test for prostate cancer)
Breast ultrasound/Breast sonogram
Biopsy
Breast MRI
Chest X-ray
Colonoscopy/Virtual Colonoscopy
Flexible Sigmoidoscopy
Pap Smear/Pap Smear - ThinPrep
Actual Cost
of Mammogram
M M D D Y Y Y Y
Pap Smear
Date:
Pap Smear
Date:
M M D D Y Y Y Y
Mammogram
Date:
Mammogram
Date:
HPV Screening Cancer Prevention Vaccine
/
- -
/
/ /
- -
.
Treatment
Date:
Treatment
Date:
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or
claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of regulatory agencies.
The Provider listed above is authorized to validate the information I have provided.
