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. Policyholder Information: *Policy Number: Patient Information: / / / / Pregnancy claims: • Date of delivery: / / Vaginal Cesarean • If not delivered, expected delivery date: / / • Please advise of any complications: For all claims, please complete all remaining sections. • Please provide the name, address and phone number of the patient’s primary treating physician. Name: Phone Number: Address: • 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 bill, UB04, or HCFA 1500.) • Was the patient confined to a rehabilitation unit as a result of this condition? No Yes (If yes, please submit the itemized bill, UB04, or HCFA 1500.) • Was patient treated in an emergency room as a result of this condition? No Yes (If yes, please submit the emergency room report, UB04, or HCFA 1500.) Hospital name: Date of treatment: / / • Was the patient transported by an ambulance as a result of this condition? No Yes (If yes, please submit the ambulance bill) • Was surgery performed as a result of this condition? No Yes (If yes, please submit a copy of the operative report, UB04, or HCFA 1500.) • Were medical imaging services (i.e. CT Scan, MRI, EEG, etc.) provided as a result of this condition? No Yes (If yes, please submit a copy of the exam report and/or billing, UB04, or HCFA 1500.) *Last Name Suffix *First Name MI *Date of Birth (mm/dd/yy) *Last Name *First Name *Date of Birth (mm/dd/yy) Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and subjects such person to criminal and civil penalties. 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) S2029 Page 2 of 2 02/14 POLICYHOLDER/PATIENT SIGNATURE FAMILY RELATIONSHIP, IF NOT POLICYHOLDER DATE