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A BenExtend claim requires supporting documentation for review of benefits such as an itemized bill if there was a hospital stay, itemized bill from physician's office, surgical report if surgery took place, Xray/Diagnostic Test reports with dates and charges if applicable, accident report if applicable, and a signed and dated Authorization for Disclosure of Health Information (HIPAA form). 3 0 obj ?/8-TEfAU,j[:b-G[DjC57H"+$-Ag(@hZ P\D=1Pt+K^bCr/L=R_+?]7:K8ND*^rZJ>\)+SO$sqSJ1VT+A'Q-ShdfdhK\Q%N%LoP*mTJ1U1["BmoP?0"U1GH. 0000043584 00000 n Your dentist should complete the Billing Dentist section, Boxes 4266 (excluding Box 53). EMnIpA`\`j9p%8Jb%g?3bB@@W^$A.t>R)@AV[$Gr+1aic5NY;`=A9#XB->:2MDO^@t[9!^9`hM)b9[&5Hfki>iJ2*idRMc*I1K7B)P.Ht.`'k-.R`,bZ1``cJ *?ZgaJ72F%->d4aYIUb3reE0'[sM)3JY+[(7="R\fM6;Q Aflac Worldwide Headquarters | Columbus, GA QQZnEET3`^=L@5Inq5fkUd?/3Y2`;02=IqDob^'R&m,FG.6*VIW,-bt2>#UYOZJj>;fU1^9uM()U8*1b A&!R^maAJpBZW3)>! 0000000446 00000 n You can provide this information in the designated space on the claim form. 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Click the Get form key to open it and start editing. 0h_D=!TqJR_)(mgd\>#ol+75J9jtBIKFJ@V(i4JVZqc++3o&'Oo?S]N51A'u=i0pZ1o;C9[qgcc?S#Dh CNbe58Z\L9(JIf#nd8N&d;_Ve"&$B6Y;]TiZ`M2[D^dN\Eb5qm'qVJ='T'4DBH2tpG-/Q,o_g=%ZaF:Y endobj /Type /Encoding [P'])96k0r/j-O-5R.B+?Ujtp8t.Wa^\9uALh!R/l:Z3W3Fi9-eo;Q)?QN/coX1HH='4^ "\1ceiPob[!+@J3(3TJ)YX)OUj[W9&;I:dYZ=kc)4eebY'g`kA>>[&O][obn/UEdfgRXrat28;.HM:HQa#NGoYVo#="o%! 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(V.ea8oM1meVG5&2$R&VHdRmbM`,/jQ'iTTlk_NLi7Pu8>hqB>F6,at#]$=1\UL'_o >> IulVik4tYO+5Y]5dC6+if#]pW>?S#%PB"2$kEPR@U_!W)J++r5@@21spCE@V_m\2SM=jcqaH.-P9&U%f /Length 310 26 0 obj 0000049255 00000 n !o5ERV47$k+S(!Xa"PN!I9]Y4"VHDRe8O[\PP>C\n_[q%@(=l5'/%#n49 Please submit the pathology report used in the diagnosis of a malignant cancer, the claimant's birth certificate, and any itemized medical bills with the diagnosis and procedure codes, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). %PDF Font (F2) Learn more claim-forms - Georgia Department of Administrative Services 2#Uk88j6F;!LPJCYg?_VnT>DO7>((M$tI28>B]"L9/3#3R1],d$6!$JJRKV2m(tG_Q]-T()Va>`2T]>l;eK>s(U,g-lu^? 0000054519 00000 n Please date and sign all required forms where indicated. ]_h\LUlKWpDX[03gS"tG,UJ0*mL9UkEk%7OIX,#u6?P_/\,44Z>m2`cW$i)b*qRV/6raU^h/W^<6?6JC;$U>eK_"kZBZcu]&\dTh"\!Q%B8?1?Rk8,^p^Wn[RC5_%c^'XQF+or (8p@RL@:%uhr=mo1Fg6rg/M;<4* *#*-ScS*/MMA_!%)m!2N2g5V( 0000001020 00000 n 16 0 obj We built our online claims process to save you time and to help give you peace of mind. No Yes Isdisabilityduetoaninjury? 29Q-bd"lOXj_`+YYr:EA4 7.XdOm?gqE4o-8r9 endobj .8k,%=2e-? Claims are subject to policy terms and conditions. [u"0oO\5'j_^6BobJWi[hgme'ak6Kf@+ 0000000009 00000 n mOu72$0Z_TEkhh3=;Da@gQ!"PXflT9`-nbs>;ZjA5? HQ$ujRc"9@)AC83@/u';(.AU@8h[,dM5@MBi91i8@]+f5P8hFJ11.%Ec:Brs4lZA';_labWMQK7-EQHe 0000035380 00000 n <>stream Short Term Disability Claim Form Instructions Aflac https://www.aflacgroupinsurance.com/docs/customer-service/claim-forms/group-disability-claims/disabilityclaimform.pdf Note: This form is for initial filing of a disability claim. <> EMnIpA`\`j9p%8Jb%g?3bB@@W^$A.t>R)@AV[$Gr+1aic5NY;`=A9#XB->:2MDO^@t[9!^9`hM)b9[&5Hfki>iJ2*idRMc*I1K7B)P.Ht.`'k-.R`,bZ1``cJ 0000000563 00000 n Aflacs Premium Life, Absence and Disability Services are available in all states, except Puerto Rico, Guam or the Virgin Islands, and are offered by Continental American Insurance Company (CAIC). >/FRGOB+OB[1iVR22-7Lnt@)K1T_gY[7;kiM;`1C&61:AoC42ST7*!-T+uZ3:t]s'Eh(_u3^02+HBBV< << ieO?mC^gEt3O?&]\X]CJV6:\OL%X;((>F1o\id;SSBij[G$R endobj 0000000686 00000 n >> << /Count 1 /First 18 0 R /Last 18 0 R >> 34KC`g@bObJ6!O^[4KaLHd&d3Z>1B[8K]!Ma[U/7j$GS6:@5eWk>jl+X?+>PG9h*%gY?g&"\0cQnsu>;4$NAR_h9iPdY^EdXqEH&r&?URsH:@b+fJ3ul5P0*OfoJU+qB&mF'>3T)PgN9! [W_J1(2pZ1HC$V;V*/7\3N-"m8ACA6(\G4_j7tLZo4PDu:9kltQ:qtrOFJei`3u25)_cfnQ2M,M>*2Sb endstream In NY, self-funded plans and absence services are administered by and insurance is offered by American Family Life Assurance Company of NY. oJ!qE004N-XBk;7k]qo&bs<9Pm9 nhH(@HB3(k..$A&2I&hNumCF[&]PjI*`R_D2M6]X>#-E#f;915&(PF6%>9Knd"E.:PO k0Q'9K%4rkrrN3]cu8p8';m8q-eHY2Sa?q0DqdO_]i_5()gWNP#-%H8k&XV=Id,j>)pb@S-4-ot]OZm4 GgU]JcO2rI@MJ!M*4mh6R`a.PLnCe-ET<>a;*-c;Tf1f endobj Offer your clients better benefit options with Aflac supplemental insurance policies. Quick steps to complete and e-sign Continuing disability claim form aflac online: Use Get Form or simply click on the template preview to open it in the editor. /Subtype /Type1 0000000326 00000 n << Nq.&`'\L*3M[AYZ6ll!-TD@!G8Dg.9W*C\Zs0MVFFq.Qdq@5EcSUjS9Pe3%!0kB*T4F <>stream /BaseFont /Helvetica-Oblique trailer<> 23 0 obj 0000054442 00000 n Gb!'5m[/fJB\_$r.pF?nb0?9.GNU`POZa=?bcjAXQ5kBDO7EHm>6&%47Ab&pW\\Ep0DVbs4$N;\XPZ>cd==.mQbW>ZXE(h&hj!?>RE;`-=j0]K(7>2TZ2c#qP2TZrnnVO>AAO\2\dZ]BV5lN<2g@`o#75u,Z^-1@eCMYZY`nV9iX]Jk15[r)/_I8dD(4^c,bTd,',#!J7^rL)<3a8P7fG%*rf%Dr0X9k_#\a>h%ENsu1N_I/E6"$"4aO%gkZ#_P8u%,_DD4Z3`,&-G'RNJo*@\gVBC#dISL`OXs`X"2c\XYOgQMjo(nU9j@@I>:$?-SG%p\5>K8mf'`2n5g](hjREP0cIi=DlJG%CduFYJX&b.fJg%;BE/2\Y7`WHp'nr&%:J'Y"Od>X7ZKtp1A2/F(Cd$FjNX24)>aWHAi,$d!uihMX'(n_)L`HY6h*Ya>%R%`kI!@VZ@Kj*91XAll1b#)Sj(43C0*ZDYVHW.o&^]8^cs$b>tO5/3)s#"+[I40fCCO0u2)j*3e@/a);GiEC,QcYi&n:D@TcfYcBYeX>jFB"0g]k[qcIUEDh\sY`P3V$amn](*)ZhblK=iC]sei38!J\1:'Sm^g=9F1G?^5X*UTD.c8Kg>?CNpfj;t*;*+5-3+-1$][#p+$s7LY3ds$(WS^3ipt1n?4gpo(-)4hZ]5TSD1c"b62Ae,uI=ht5%%pur?]C"mK+/"n@,G@E!%Tm_Z('e6`@=LQJX>m2u!EdFdln=`n_1KT(Jdtn&@OhFd_-qh%AS.4e_"nG>AmU@I`/XL)S*AH60oN#\=,_M)mR[KZ"p#@QKTXhSQoBW6Pc2r1abgMO4mbWZJ_P.S0Z?CC27h1I4*Xt]'k^P`c1tChMX"]cTFjUN>O%@eLs@rgmWT?ci5AXtahm=GCI0lG41Vu%ET![Pf]&aI:B+JKG^84P$0u2CD+0?/0su!u;km^rug0:2"VI(*%/+bQ/)HNQVs0JlC_#J`D*lKqGe.5CT5W%::0+m=,"tDhT:Jf.Zq_h(jA)][.]!1gIc_g$e.NIY7[Dn[]g&+*Dc(B:jSF2;0_UcSO=hWJLHLeZ$&=Ibr9.GHm'mXS3P2Ek.5Ya!YtUFO)#kgZ.eZ`LC0e]4]aW"'asKdg_Z"5EE^C=)[U)8)55iHZq2>kKE;Zj.Do+X/DSW[g,Q>hSOSQ$%5h_?(@[q&hh1R=9+/)8;"A^Hn>PPi5t$eN5g`uORs-`,rNBc0.X_)BIVn/qs?1NU@,SCi]^G`[P0TK1pr%^qAZJ4DVn/T'u"#MW0u^k8/G"%kaRF,8qKUN?
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