[Form] Critical Illness Wellness Form

CRITICAL ILLNESS CLAIM FORM Failure to complete all sections may result in a delay in processing this claim. Please review your policy for specific benefits covered under your plan. To prevent delays, please provide documentation from your healthcare provider to support this claim. Disclaimer: Some of the services listed may not be covered by your policy. Please sign the attached HIPAA Form and return it with the completed claim form. • Please indicate the condition that the patient is filing for below: Cancer; Carcinoma in situ- Please submit a copy of the pathology report from which the condition was diagnosed. Heart Attack: Please submit a copy of the discharge summary, cardiology consult report, cardiac catheterization report, history & physical, and ER notes. Coronary Artery Bypass Surgery: Please submit a copy of the operative report for the procedure. Major Organ Transplant: Please submit a copy of the operative report for the procedure. Stroke: Please submit a copy of the discharge summary, MRI and/or CT test reports from the initial diagnosis, as well as proof of permanent neurological damage (i.e. follow up CT and/or MRI reports, office notes from neurologist or therapist, etc.) Renal Failure: Please submit proof of the start date for dialysis or the operative report for transplant. The End Stage Renal Disease Medical Evidence Report is preferred. Heart Event: Please submit a copy of the operative report for the procedure. • 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.) CAF001CI-13v4