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¢ CANCER SCREENING BENEFIT CLAIM FORM DUCK If you are interested in filing your claim online, register using aflac.com/smartclaim. Benefits of filing your claim online include faster claim processing time and receiving claim communications by email. Please read all instructions. Failure to follow these instructions could delay the processing of your claim. • Do not include receipts, statements or other claim documentation with this form. • Do not write on form except as instructed. • Sign, date and fax or mail the completed form to the Aflac fax number/address shown below. • Use black or blue ink only and print legibly when completing this form in its entirety. • Mark only wellness exam boxes for test(s) and/or treatment(s) received. • Failure to complete all sections may result in a delay in processing this claim. • Some types of tests and/or treatment listed may not be covered by your policy. Please keep a copy of this completed form for your records. Please print a separate form for each additional family member or call 1-800-99-AFLAC (1-[PHONE REDACTED]) to request additional forms. Claims for all other benefits covered under this policy must be filed separately using the claim forms available at aflac.com or by calling 1-800-99-AFLAC (1-[PHONE REDACTED]). CW06197CA Page 1 of 2 05/17 American Family Life Assurance Company of Columbus (Aflac) ATTN: Claims Department • 1932 Road • Columbus, GA 31999 For information or to check claim status, visit aflac.com or call 1-800-99-AFLAC (1-[PHONE REDACTED]) Claims may be faxed to 1-877-44-AFLAC (1-[PHONE REDACTED]) ---PAGE BREAK--- Policyholder Information: Policy Number: Patient Information: Home Address City State Zip Code Last Name First Name Date of Birth (mm/dd/yy) POLICYHOLDER/PATIENT SIGNATURE FAMILY RELATIONSHIP, IF NOT POLICYHOLDER DATE Physician's Street Address Physician's City State: Zip: Physician's Name Physician's Phone Number: Check box if this is permanent address change. CANCER SCREENING BENEFIT CLAIM FORM Chest X-ray Scopes (Oscopies) Scans/MRI Pap Smear/Pap Smear-ThinPrep HPV Screening Bone Marrow Screening Cervical Cancer Screening Cancer Vaccine Genetic Testing P32 Uptake Test I I I 111111111111111 ITJ 111111111111 □ / - - / I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I ITJ I I I I I I □ I I I I I I I I I I I I I I I I I 11 I I I I I I I I I I 11 I I I I I I I I □ □ □ □ □ I I I I I I I I I I I I I I I I I I I I I I I I I I I □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I IITJ 111111 Sex: Male Female / / Relationship: Primary Policyholder Spouse Dependent Child M M D D Y Y Y Y M M D D Y Y Y Y M M D D Y Y Y Y Pap Smear Treatment Mammogram Date: Date: Date: Serum Protein Electrophoresis CA153 (blood test for breast cancer monitoring) Hemocult Stool Specimen Thermography CEA (blood test for colon cancer) PSA (blood test for prostate cancer) CA125 (blood test for ovarian cancer) Ultrasounds Mammogram Biopsy Actual Cost of Mammogram - - . 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. The Physician listed above is authorized to validate the information I have provided. CW06197CA Page 2 of 2 06/17 American Family Life Assurance Company of Columbus (Aflac) ATTN: Claims Department • 1932 Road • Columbus, GA 31999 For information or to check claim status, visit aflac.com or call 1-800-99-AFLAC (1-[PHONE REDACTED]) Claims may be faxed to 1-877-44-AFLAC (1-[PHONE REDACTED]) SIGN