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Cancer Checklist • Is this the initial claim for this cancer diagnosis? No Yes (If yes, please submit the initial pathology report or exam that diagnosed cancer.) • Please be sure to include the following information along with this claim form: positive Pathology Report and itemized bills from facility including diagnosis and/or procedure codes and charge amounts (Itemized bills may include but are not limited to the following: UB04 from your provider, HCFA1500 from your provider, etc.) • Has the patient been diagnosed with cancer? No Yes (If yes, please submit the initial pathology report or exam that diagnosed cancer.) • Type of cancer: • Date of initial diagnosis: / / • First date of treatment for this diagnosis: / / Policyholder Information: This * denotes a required field. *Policy Number: / / - - - Patient Information: *Last Name Suffix *First Name MI *Date of Birth (mm/dd/yy) Telephone Number where we can reach you *Home Address *City *State *Zip Code *Last Name *First Name *Date of Birth (mm/dd/yy) / / *Sex: Male Female *Relationship: Primary Policyholder Spouse Dependent Child Check box if this is a permanent address change. I I I I I I I I I 111111111111111 I I I 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 ITJ 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 □ □ □ □ □ □ □ □ □ CANCER CLAIM FORM Affac. Thank you for trusting Aflac with your Cancer needs. To file your claim online or upload documentation on an existing claim, register on Aflac.com or download the MyAflac mobile app. To prevent delays, please provide documentation from your healthcare provider to support this claim. 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. Service related items can be obtained directly from the patient’s healthcare provider(s) by requesting a UB04 hospital bill or HCFA 1500 non-hospital bill. Failure to complete all sections may result in a delay in processing this claim. Disclaimer: Some of the services listed may not be covered by your policy. 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]) S00220 Page 1 of 2 02/14 ---PAGE BREAK--- 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: / / / / I I I I I I I I I 111111111111111 I I I 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 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ *Last Name Suffix *First Name MI *Date of Birth (mm/dd/yy) *Last Name *First Name *Date of Birth (mm/dd/yy) • Was the patient confined to the hospital as a result of this diagnosis? No Yes (If yes, please submit the itemized hospital bill, UB04 from your provider, or HCFA 1500 from your provider.) Hospital name City State • Please provide the name, address and phone number of the patient’s primary treating physician. Name: Phone Number: Address: • Was the patient treated by any other physicians? No Yes If yes, physician’s name(s): Phone Number(s): Address: • Did the patient undergo surgery for this condition? No Yes (If yes, please submit a copy of the operative report, surgeon’s bill and anesthesia bill to include charges.) Where was the surgery performed? Office Surgical Center Outpatient Hospital Inpatient Hospital Name of facility: Address: • Has the patient received chemotherapy? No Yes (If yes, please submit a copy of itemized billing.) Name of facility where chemotherapy was received: Address: • Has the patient received oral chemotherapy? No Yes (If yes, please submit pharmaceutical statements.) • Has the patient received topical chemotherapy (Treatment with anticancer drugs in a lotion or cream applied to the skin)? No Yes (If yes, please submit pharmaceutical statements.) • Has the patient received radiation therapy? No Yes (If yes, please submit a copy of itemized billing.) Name of facility where radiation was received: Address: • Transportation/Lodging Information: To be completed if you are filing a claim for transportation or lodging: (please submit the hotel receipts and mileage information) *For additional information, please refer to your policy language. Date To/From Round-Trip Mileage Type of Treatment 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. POLICYHOLDER/PATIENT SIGNATURE FAMILY RELATIONSHIP, IF NOT POLICYHOLDER DATE 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]) S00220 Page 2 of 2 02/14 SIGN