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0000004521 00000 n Please use the claim appeal form to organize your request. 0000001378 00000 n 0000006887 00000 n
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• Do not fax or photocopy this document.

%PDF-1.4 %���� 0000012828 00000 n 0000058322 00000 n 0000002892 00000 n 0000008400 00000 n 0000008180 00000 n SICKNESS CLAIM FORM ... (1-800-992-3522) or visit our Web site at aflac.com Toll-free fax number 1-877-44-AFLAC (1-877-442-3522) SICKNESS CLAIM FORM – PHYSICIAN'S STATEMENT Failure to complete this form in its entirety may result in a delay in processing this claim. �_O~��혺��:M��k���Gf��~�k#H�n���3����3*�~~�ނ�,����Q)�� � 0000003004 00000 n HOSPITAL INDEMNITY CLAIM FORM INSTRUCTIONS . 0000003727 00000 n 0000005415 00000 n

0000009438 00000 n 0000008850 00000 n Page 2 04/05 SECTION B: PHYSICIAN'S STATEMENT Please answer each question COMPLETELY. MAILING ADDRESS: 1120 15th Street, Augusta, GA 30912 We have 4 images about aflac physician visit claim form including images, pictures, photos, wallpapers, and more. H�b``Pf``�� ��1`PZ ����A���1�)�͂��ƒaB�],zN,``����r�9�̀�!Q���������є�U�G 8U�`�320�/�L@�` �C� endstream endobj 42 0 obj 114 endobj 8 0 obj << /Type /Page /Parent 3 0 R /Resources 9 0 R /Contents [ 18 0 R 20 0 R 22 0 R 24 0 R 28 0 R 30 0 R 32 0 R 34 0 R ] /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 9 0 obj << /ProcSet [ /PDF /Text ] /Font << /TT2 11 0 R /TT4 13 0 R /TT6 14 0 R /TT8 25 0 R >> /ExtGState << /GS1 40 0 R >> /ColorSpace << /Cs6 15 0 R >> >> endobj 10 0 obj << /Type /FontDescriptor /Ascent 905 /CapHeight 0 /Descent -211 /Flags 32 /FontBBox [ -665 -325 2000 1006 ] /FontName /OKNCEP+Arial /ItalicAngle 0 /StemV 94 /XHeight 515 /FontFile2 37 0 R >> endobj 11 0 obj << /Type /Font /Subtype /TrueType /FirstChar 95 /LastChar 95 /Widths [ 995 ] /Encoding /WinAnsiEncoding /BaseFont /OKNCDL+Helvetica-AFLAC-Bold /FontDescriptor 16 0 R >> endobj 12 0 obj << /Type /FontDescriptor /Ascent 905 /CapHeight 718 /Descent -211 /Flags 32 /FontBBox [ -628 -376 2000 1010 ] /FontName /OKNCEN+Arial,Bold /ItalicAngle 0 /StemV 144 /XHeight 515 /FontFile2 35 0 R >> endobj 13 0 obj << /Type /Font /Subtype /TrueType /FirstChar 36 /LastChar 122 /Widths [ 556 0 0 238 333 333 0 0 278 0 278 0 556 556 556 556 0 556 0 0 0 0 333 333 0 0 0 0 0 722 722 722 722 667 611 0 722 278 0 0 611 833 722 778 667 0 722 667 611 722 667 944 0 667 0 0 0 0 0 0 0 556 611 556 611 556 333 611 611 278 0 556 278 889 611 611 611 611 389 556 333 611 556 778 556 556 500 ] /Encoding /WinAnsiEncoding /BaseFont /OKNCEN+Arial,Bold /FontDescriptor 12 0 R >> endobj 14 0 obj << /Type /Font /Subtype /TrueType /FirstChar 39 /LastChar 241 /Widths [ 191 333 333 0 0 278 333 278 0 556 556 556 556 556 556 0 556 556 556 278 0 0 0 0 0 0 667 667 722 722 0 611 778 722 278 0 0 556 833 722 0 667 0 722 667 0 0 0 944 0 667 611 0 0 0 0 0 0 556 556 500 556 556 278 0 556 222 0 500 222 833 556 556 556 556 333 500 278 556 0 722 500 500 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 350 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 556 ] /Encoding /WinAnsiEncoding /BaseFont /OKNCEP+Arial /FontDescriptor 10 0 R >> endobj 15 0 obj [ /ICCBased 38 0 R ] endobj 16 0 obj << /Type /FontDescriptor /Ascent 856 /CapHeight 0 /Descent -342 /Flags 32 /FontBBox [ -33 -342 1341 856 ] /FontName /OKNCDL+Helvetica-AFLAC-Bold /ItalicAngle 0 /StemV 0 /FontFile2 36 0 R >> endobj 17 0 obj 1439 endobj 18 0 obj << /Filter /FlateDecode /Length 17 0 R >> stream DateofPhysician’sVisit: *Pleasesubmitonly

If you are filing for a health screening on your Hospital Indemnity, Accident, or Critical Illness plan for Coronavirus (COVID-19) testing, select Biometric Screening as your exam.

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