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Please use the claim appeal form to organize your request. 0000001378 00000 n
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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
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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�)�͂��aB�],zN,``����r�9�̀�!Q���������є�U�G
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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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