Loading...Download Aflac Cancer Screening Wellness Benefit Claim Form. This form is designed to provide an annual cancer screening (after the first 12 months of insurance), for those who have the Cancer Screening Benefit. Aflac also provides pap smear and mammogram benefits once per year. Use only blue or black ink while completing this entire form.
How To Write
Step 1 – Cancer Screening Wellness Benefit Claim Form
- Read all information on the cover of this form – Any information will result in processing delays.
- Policy Number
- Policyholder’s Last Name
- Policyholder’s Date of Birth (mm/dd/yyyy)
- Zip Code of Mailing Address
- Patient’s First Name
- Middle Initial
- Patient’s Last Name
- Relationship to Policyholder (check one)
- Patient Sex (check one)
- Patient Date of Birth mm/dd/yyyy
- Wellness Exam Treatment Date mm/dd/yyyy (check all that apply)
Step 2 – Doctor or Medical Facility Name and Address – This section must be completed entirely:
- Phone Number (with area code)
- Full Name
- Street Address
- City
- State
- Zip Code
- Read – Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Step 3 – Once you have read the sentences, if you understand and agree, provide your signature as follows:
- Policyholder Signature
- Printed Name
- Date (mm/dd/yyyyy)