Fillable Hospital Indemnity Claim Form

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Hospital Indemnity Claim Form

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CONTINENTAL AMERICAN INSURANCE COMPANY
Post Office Box 84075 * Columbus, GA. 31993
Phone (800) 433-3036 * Fax (866) 849-2970
HOSPITAL INDEMNITY CLAIM FORM INSTRUCTIONS
To avoid delays in processing of your claim form, complete each section attaching documentation below when
it applies.
Supporting Documentation Needed
Itemized bill if there was a hospital stay (UB04 from the hospital or medical facility)
Chart Note to include admission and discharge paperwork if there was a hospital stay
Itemized bill from physician’s office (HCFA 1500 from treating physician’s office)
Surgical Report if surgery took place
Follow Up Visit-receipts for follow up visits or physical therapy with dates and charges if applicable
Xray/Diagnostic Tests-receipts with dates and charges if applicable
Accident Report-if applicable (ex: police report)
Benefit Assignment-Benefits are payable to the policy holder unless written authorization
is received from
you or your healthcare provider to assign benefits to the provider. If you choose to assign benefits,
attach a signed and written request.
Email form to groupclaimfiling@aflac.com or fax to 1.866.849.2970.
CONTINENTAL AMERICAN INSURANCE COMPANY
Post Office Box 84075 * Columbus, GA. 31993
Phone (800) 433-3036 * Fax (866) 849-2970
HOSPITAL INDEMNITY CLAIM FORM
AUTHORIZATION
Several states require that the following statement appear on claim forms: Any person who knowingly attempts to
defraud any insurance company, files a statement of claim containing any materially false, incomplete or
misleading information, is guilty of a crime.
I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my
knowledge and belief. I have read the fraud notice included in this form.
Policyholder’s signature: Date:
Patient’s Signature: Date:
POLICYHOLDER/PATIENT INFORMATION
Employer’s Name
Policyholder’s Email Address
Policyholder’s Name
Social Security No
Date of Birth
Gender
Policyholder’s Address City State Zip Code
Policyholder’s Telephone No. (with area code)
Patient’s Name (Person who is sick or injured)
Patient’s Date of
Birth
Patient’s
Gender
Relationship to Policyholder
*By providing your e-mail address above, you consent to the use of electronic transactions in connection with your CAIC policies, contracts,
and/or accounts to the extent available permitted by law (which may include, but not limited to: invoices, claim correspondence, contracts,
surveys, and other materials that CAIC is, or may be, legally required to deliver to you).
CONTINENTAL AMERICAN INSURANCE COMPANY
Post Office Box 84075 * Columbus, GA.
31993 Phone (800) 433-3036 * Fax (866) 849-
2970
Please sign the attached HIPAA form and return it with the completed claim form.
*****If filing a claim within the first policy year for benefits, medical records may be requested*****
Is medical treatment due to an injury?
No Yes
If yes, provide the date of the injury.
Describe how the injury occurred.
Loc
ation of the injury: On the job Off the job
W
as the patient injured in a motor vehicle accident?
No Yes
(
If yes, attach a copy of the police report.)
I
s treatment related to an illness? No Yes
I
f yes, complete the following questions related to the illness.
What is the illness diagnosis?
W
hen did symptoms first occur?
W
hat is the first date of treatment for the illness?
I
f diagnosed with cancer, what is the date of the initial diagnosis?
(Attach a copy of the pathology report.)
Was the patient treated by any other physicians for this illness or a related condition?
No Yes
If yes, provide the physician’s information below.
Treatment Date
Physician Name
Address
City, State, Zip
Phone Number
PREGNANCY CLAIMS
Date of delivery:
Type of delivery: Vagina
l
Caesarean
If not delivered, expected delivery date:
What was the date of your last menstrual period?
List any complications related to your pregnancy:
Complete the remaining sections for ALL claims.
Patient’s primary treating physician.
Physician Name:
Address:
City, State, Zip
Phone:
Was the patient confined to the hospital as a result of this condition?
No Yes
(If confined, please submit copy of patient’s admission and discharge papers or a copy of a UB-0
4 billing invoice from the
hospital.)
Hospital/Facility Name:
Phone:
Admission Date:
Discharge Date:
Employer Facility Benefit Provision
(for insureds who have employer facility benefits)
Where patient was admitted, confinement or received treatment:
Hospital/Facility Name:
Address:
City, State, Zip
Phone:
Is this facility also your place of employment?
No Yes
If no, does this facility partner with your employer’s healthcare system?
No Yes
Was the patient confined to the intensive care unit as a result of this condition?
No Yes
(If yes, submit copy of a UB-04 billing invoice from the hospital facility to identify the days spent in the intensive care unit.)
Was the patient treated in an emergency room as a result of this condition?
No Yes
(If yes, submit emergency room admission and discharge papers.)
Was surgery performed as a result of the medical condition?
No Yes
(If yes, submit a copy of the operative report.)
**For outpatient prescription drug benefits, please submit pharmacy receipts showing the name of the prescription, the physician
name prescribing it and the date prescribed.
CONTINENTAL AMERICAN INSURANCE COMPANY
Post Office Box 84075 * Columbus, GA. 31993
Phone (800) 433-3036 * Fax (866) 849-2970
AUTHORIZATION TO OBTAIN INFORMATION
MAIL TO: Continental American Insurance Company
P.O. Box 84075
Columbus, Georgia 31993
CALL: 1.800.433.3036 (toll-free)
CLAIM FAX: 1.866.849.2970
Primary Certificateholder’s Name: SSN(optional): Date of Birth:
Certificate Number(s):
Address:
Name of Individual Subject to Disclosure (If not the primary Certificateholder): Date of Birth:
Relationship to Primary Certificateholder:
Self Spouse Domestic Partner Child Stepchild Grandchild
I.
Authorization:
For the purpose of evaluating my eligibility for insurance and for benefits under an existing certificate, including checking
for and resolving any issues that may arise regarding incomplete or incorrect information on my application for coverage
and/or claim form, I hereby authorize the disclosure of the following information(defined below) about me and, if
applicable, my dependents, from the sources listed below to Continental American Insurance Company (CAIC), or any
person or entity acting on its part, to include American Family Life Assurance Company of Columbus and American
Family Life Assurance Company of New York (collectively, “Aflac).
II.
Disclosure of Health Information:
Health information may be disclosed by any health care provider, health plan (including CAIC or Aflac, with respect to other
CAIC or Aflac coverages) or health care clearinghouse that has any records or knowledge about me. Health care provider
includes, but is not limited to, any licensed physician, medical or nurse practitioner, nurse, pharmacist, osteopath,
psychologist, physical or occupational therapist, chiropractor, dentist, audiologist or speech pathologist, podiatrist, hospital,
medical clinic or laboratory, pharmacy, rehabilitation facility, nursing home or extended care facility, prescription drug
database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be
disclosed by any insurance company or the Medical Information Bureau (MIB). Health information includes my entire
medical record, but does not include psychotherapy notes. Some information obtained may not be protected by certain
federal regulations governing the privacy of health information, but the information is protected by state privacy laws and
other applicable laws. CAIC will not disclose the information unless permitted or required by those laws.
III.
Rights and Expiration:
I understand that I may revoke this authorization at any time, except to the extent that CAIC or Aflac has taken action in
reliance on this authorization. If I revoke this authorization, CAIC may not be able to evaluate my application for coverage
and/or claim. To revoke this authorization, I must provide a written and signed revocation to CAIC at the address or fax
number above. Unless otherwise revoked, this authorization shall remain in effect for two (2) years from the date signed
or upon my death, whichever occurs first. I agree that a copy of this authorization is as valid as the original and that I or an
authorized representative may request a copy of this authorization.
IV.
Notice:
I understand that CAIC is not conditioning payment, enrollment, or eligibility for benefits on whether I sign this
authorization. I understand that if the information disclosed is protected health information relating to a health plan and the
person or entity receiving the information is a not a health care provider or health plan covered by federal privacy
regulations, the information disclosed may be redisclosed by such person or entity and will likely no longer be protected
by the federal privacy regulations.
•
If records are on an adult dependent, (e.g. spouse, child over 18), the dependent must sign this form
•
If records are on a minor child the natural parent or legal guardian must sign on their behalf.
Signature of Individual Subject to Disclosure Date Signed
Legal Representative’s Printed Name Legal Representative’s Signature Legal Relationship
If signed by a legal representative (e.g. Legal Guardian, Estate Administrator, Power of Attorney)
AGC06105
Date Signed
Electronic Funds Transaction Authorization
Send to: Continental American Insurance Company
Post Office Box 84075
Columbus, Georgia 31993
Phone: (800) 433-3036 Fax (866) 849-2970
Email: groupclaimfiling@aflac.com
Authorization Agreement for Direct Deposit
I would like to: ☐ Start ☐Stop ☐Change direct deposit of my claim payment(s).
Account Type:
☐Checking ☐Savings
**** Please provide a blank voided check or
direct deposit form from your financial
institution. Incomplete or inaccurate
information will not be processed.
9-Digit Routing Number:
Account Number:
Name of Financial Institution:
Address:
City:
State:
Zip:
Phone:
I authorize Continental American Insurance Company (CAIC) to initiate credit entries, and, if errors occur, I
authorize the correction of entries to my account as indicated. This authorization remains effective and in full force
until CAIC receives written notification from me of its termination in such time and in such manner to afford CAIC a
reasonable opportunity to act on it. Please notify CAIC immediately if your financial institution information has
changed by sending notification to the address indicated above. Should you have any questions, please contact us at
1-800-433-3036.
Policy/Certificate Holder’s Name (Print):
Address:
City/State/Zip:
Phone #:
E-mail Address:
Employer Name or Group #:
Certificate #:
***By providing your e-mail address above, you consent to the use of electronic transactions in connection with your CAIC policies, contracts, and/or
accounts to the extent available and permitted by law (which may include, but not limited to: invoices, claim correspondence, contracts, surveys, and
other materials that CAIC is, or may be, legally required to deliver to you)
Note: Forms received without signature will not be processed. Electronic signatures not accepted.
Policy/Certificate Holder Signature (Required) Date Signed:
Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. Aflac is
not licensed to solicit
business in New York, Guam, Puerto Rico, or the Virgin Islands. For groups sitused in California, coverage is underwritten by Continental American Life Insurance
Company. For groups sitused in New York,
coverage is underwritten by American Family Life Assurance Company of New York.
Continental American Insurance Company • 1600 Williams St • Columbia, South Carolina 29201 • 1-800-433-3036 toll-free • 1-866-849-2970 fax
FRAUD WARNING NOTICES
For use with Claim Forms
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
ALASKA:
A person who knowingly and with intent to
injury,
defraud or deceive an insurance company files a
claim
containing false, incomplete, or misleading
information may be
prosecuted under state law.
IDAHO:
Any person who knowingly, and with intent to
defraud
or deceive any insurance company, files a
statement of claim
containing any false, incomplete, or
misleading information is
guilty of a felony.
ARIZONA:
For your protection Arizona law requires
the
following statement to appear on this form. Any
person who
knowingly presents a false or fraudulent
claim for payment of a
loss is subject to criminal and
civil penalties.
INDIANA:
A person who knowingly and with intent to
defraud
an insurer files a statement of claim containing
Any false,
incomplete, or misleading information
commits a felony.
ARKANSAS:
Any person who knowingly presents a
false or
fraudulent claim for payment of a loss or benefit
or knowingly
presents false information in an application for insurance is
guilty of a crime and may be
subject to fines and confinement
in prison.
KENTUCKY:
Any person who knowingly and with intent to
defraud any insurance company or other person files a
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.
CALIFORNIA:
For your protection California law
requires the
following to appear on this form:
Any person who knowingly presents a false or
fraudulent claim
for the payment of a loss is guilty of a
crime and may be subject
to fines and confinement in
state prison.
LOUISIANA:
Any person who knowingly presents a
false or
fraudulent claim for payment of a loss or benefit
or knowingly
presents false information in an application
for insurance is
guilty of a crime and may be subject to
fines and confinement
in prison.
COLORADO:
It is unlawful to knowingly provide false,
incomplete, or misleading facts or information to an
insurance
company for the purpose of defrauding or
attempting to
defraud the company. Penalties may
include imprisonment,
fines, denial of insurance and civil damages. Any insurance
company or agent of an insurance company who knowingly
provides false,
incomplete, or misleading facts or information
to a
policyholder or claimant for the purpose of defrauding
or
attempting to defraud the policyholder or claimant
with regard
to a settlement or award payable from
insurance proceeds
shall be reported to the Colorado
division of insurance within
the department of regulatory agencies.
MAINE:
It is a crime to knowingly provide false,
incomplete or
misleading information to an insurance
company for the
purpose of defrauding the company.
Penalties may include
imprisonment, fines or a denial of
insurance benefits.
MARYLAND:
Any person who knowingly and willfully
presents
a false or fraudulent claim for payment of a loss
or benefit or
who knowingly and willfully presents false
information in an
application for insurance is guilty of a
crime and may be
subject to fines and confinement in
prison.
DELAWARE:
Any person who knowingly, and with intent to
injure, defraud or deceive any insurer, files a statement of
claim containing any false, incomplete or misleading
information is guilty of a felony.
MINNESOTA:
A person who files a claim with intent to defraud
or helps commit a fraud against an insurer is guilt of a crime.
DISTRICT OF COLUMBIA: WARNING:
It is a crime to provide
false or misleading information to an insurer for
the purpose of
defrauding the insurer or any other
person. Penalties include
imprisonment and/or fines. In
addition, an insurer may deny
insurance benefits if false
information materially related to a
claim was provided
by the applicant.
NEW HAMPSHIRE:
Any person who, with a purpose to injure,
defraud, or deceive any insurance company, files a
statement
of claim containing any false, incomplete, or misleading
information is subject to prosecution and punishment for
insurance fraud, as provided in RSA 638:20.
FLORIDA:
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.
NEW JERSEY:
Any person who knowingly files a statement of
claim containing any false or misleading
information is subject
to criminal and civil penalties.
FRAUD WARNING NOTICES (CONT.)
For use with Claim Forms
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
NEW MEXICO:
Any person who knowingly presents a
false or
fraudulent claim for payment of a loss or benefit or
knowingly
presents false information in an application for
insurance is
guilty of a crime and may be subject to civil
fines and criminal
penalties.
TENNESSEE:
It is a crime to knowingly provide false,
incomplete or misleading information to an insurance
company
for the purpose of defrauding the company.
Penalties include
imprisonment, fines and denial of
insurance benefits.
NEW YORK:
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 shall also be subject to a civil
penalty not to exceed five
thousand dollars and the stated
value of the claim for each
such violation.
TEXAS:
Any person who knowingly presents a false or
fraudulent claim for the payment of a loss is guilty of a crime
and may be subject to fines and confinement in
state prison.
OHIO:
Any person who, with intent to defraud or knowing
that
he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive
statement is guilty of insurance fraud.
VIRGINIA
: It is a crime to knowingly provide false,
incomplete
or misleading information to an insurance
company for the
purpose of defrauding the company.
Penalties include
imprisonment, fines and denial of
insurance benefits.
OKLAHOMA: WARNING: Any person who knowingly, and with
intent to injure, defraud or deceive any insurer, makes any claim
for the proceeds of an insurance policy containing any false,
incomplete or misleading information
is guilty of a felony.
WASHINGTON:
It is a crime to knowingly provide false,
incomplete, or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines, and denial of insurance
benefits.
OREGON:
Any person who, with intent to defraud or
knowing
that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or
deceptive
statement may be guilty of insurance fraud.
RHODE ISLAND and WEST VIRGINIA:
Any person who
knowingly presents a false or fraudulent claim for payment
of
a loss or benefit or knowingly presents false information
in an
application for insurance is guilty of a
crime and may
be
subject to fines and confinement in prison.
PENNSYLVANIA
: 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.
ALL OTHER STATES:
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.
PUERTO RICO:
Any person who knowingly and with the
intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a
loss
or any other benefit, or presents more than one claim
for the
same damage or loss, shall incur a felony and,
upon
conviction, shall be sanctioned for each violation with
the
penalty of a fine of not less than five thousand dollars ($5,000)
and not more than ten thousand dollars ($10,000), or a fixed
term of imprisonment for three (3)
years, or both penalties.
Should aggravating circumstances
are present, the penalty thus
established may be increased
to a maximum of five (5) years, if
extenuating circumstances are present, it may be reduced to a
minimum of two (2) years.
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Hospital Indemnity Claim Form

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Completed 18 July 2020

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