HOW TO FILE ACCIDENT AFLAC CLAIM Step 1: Please complete the attached Accident Claim Form and follow the check list guidelines below. Have the patient or policy holder complete and sign Page 1 & 2 Sign the Claim Authorization form Sign Summit authorization form if necessary sign specialty care (St. John s) Police report (if a motor vehicle accident) Death Certificate (if patient is deceased due to accident) Step 2: We at Summit Insurance understand that injuries can lead to difficult times, again we are here to help. Please obtain and forward to us copies of the following items as you obtain them to expedite your claim. Gather and submit copies of the following: (as applicable) Initial visit to physician, ER, or Urgent Care s encounter notes and detailed billing Operative report (if surgery needed to correct injury) Follow-up visits (detailed billing) CT, MRI or EEG reports and billing(for policies issued after June 2006) Physical Therapy Appliance (crutches, wheelchair, leg brace etc) Prosthesis Ambulance Transportation & Lodging (if patient was hospitalized more than 100 miles from home) Contact us at: 307-733-2055 or 800-261-7612
HOW TO FILE AN AFLAC DISABILITY CLAIM Please complete the attached Disability Claim Form and follow the check list guidelines below. Initial/First Claim for Disability Have the employer complete and sign page 2 Have your physician complete and sign page 3 & 4 Have the patient sign the Authorization form If you are self-employed, send a copy of your current business license and most recent quarterly tax records. Continuing/Second and Subsequent Disability Claims Have your physician complete and sign page 2 Have your employer complete and sign page 3 Contact us at: 307-733-2055 or 800-261-7612
HOW TO FILE AN AFLAC CANCER CLAIM Step1: Please complete the attached Cancer Claim Form and follow the check list guidelines below: Sign the Aflac Authorization form Sign Summit authorization form if necessary sign specialty care (St. John s) Pathology report diagnosing cancer. Initial physician notes and detailed billing. Step 2: We at Summit Insurance understand that fighting cancer can be a daunting task, again we are here to help. Please try to obtain and forward to us copies of the following items as you receive them to expedite your claim. Gather and submit copies of the following bills (as applicable) Operative report Anesthesia Ambulance Chemotherapy Treatment Radiation Treatment Experimental Treatment Stem Cell or Bone Marrow Transplantation Anti-Nausea drugs Immunotherapy Blood and Plasma transfusions during hospital confinement Transportation & Lodging (only if patient is receiving treatment more than 50 miles from home) Extended-Care Facility, Home Health Care or Nursing Services Prosthesis Contact us at: 307-733-2055 or 800-261-7612
HOW TO FILE AN AFLAC HOSPITAL CLAIM Form is used to file claims for the following AFLAC policies: Hospital Protection: In-patient Confinement, Out-patient Surgery, Invasive diagnostic exams Hospital Intensive Care: In-patient intensive care confinement, ambulance, organ transplant Personal Sickness: In-patient Confinement, major diagnostic exam, surgery Please complete the attached Sickness Claim Form and follow the check list guidelines below: Have the policy holder complete claim form Sign the Authorization form Gather and submit copies of the following detailed bills and accompanying DR. notes (as applicable) Operative report Invasive diagnostic exams (colonoscopy, sigmoidoscopy, arthroscopy etc) Dr Visit We can be reached at 307-733-2055 or 800-261-7612
HOW TO FILE AN AFLAC CLAIM Specified Health Event Claims Please complete the attached Accident Claim Form and follow the check list guidelines below. Have your physician complete and sign page 2 & 3 Sign the Authorization form Gather and submit copies of the following bills (as applicable) Ambulance Continuing Care Transportation & Lodging (only if patient is receiving treatment more than 50 miles from home)
HOW TO FILE AN AFLAC CLAIM Dental Claims All dental claims will need to be submitted on the attached American Dental Association (ADA) claim form. Have the provider fill out the ADA claim form Sign the Authorization IMPORTANT! If you want the payment to come directly to you, please be sure that box 37 is blank. If you sign in this box or if the dentist puts signature on file then payment will be issued to the dentist. At Summit Insurance we are dedicated to ensuring that your AFLAC claim goes as smoothly as possible. As your AFLAC agents, we are here to answer your questions and help you with the more complicated issues. We can be reached at 307-733-2055 or 800-261-7612 In an effort to assist you in submitting your AFLAC claims for the fastest response, we have included: Claim Form Fax Cover Sheet Authorization Form For faster service fax your claims to 877-442-3522