Aglc105137 - Preventive Care Benefit Claim Form printable pdf download

Preventive Care Benefit Claim Form

You are eligible to receive the amount shown in your Schedule of Benefits per Calendar Year per Insured if you have a health screening

test. Health Screening Tests include but are not limited to the following:

CRITICAL CARE Policy - Preventive Care Benefit

Test are limited to: Blood Test for triglycerides; Breast ultrasound; Chest X-ray; Colonoscopy; Electrocardiogram; Fasting blood glucose

test; Flexible sigmoidoscopy; Hemocult stool analysis; Mammography; Pap test; PSA- blood test for prostate cancer; Serum cholesterol

test to determine level of HDL and LDL; Serum Protein Electrophoresis - blood test for myeloma; and Stress test on a bicycle or treadmill.

CANCER CARE Policy - Specified Disease Screening Tests Benefit

Tests should be performed on an Insured Person Age 35 and older for all tests combined: Breast ultrasound, Pap smear, Mammogram,

Biopsy, Flexible Sigmoidoscopy, Hemocult Stool Specimen, Chest X-ray, CEA (blood test for Colon Cancer), CA 125 (blood test for Ovarian

Cancer), PSA (blood test for Prostate Cancer), Thermography or Colonoscopy.

To submit a claim:

1. Complete this form.

2. Attach a copy of the itemized bill from your provider showing the service date and exam(s) performed.

3. Mail completed claim to P.O. Box 9678 Amarillo, TX 79105-9678.

Or you may submit your claim by fax to 713-831-3028.

INSURED'S STATEMENT

Policy No. ____________________________________________________________________________________________________

Name ______________________________________________________________________________________________________

Date of Birth __________________________________________________________________________________________________

Address______________________________________________________________________________________________________

City __________________________________________ State __________________________________ ZIP __________________

AUTHORIZATION AND ACKNOWLEDGEMENT

I hereby certify that the statements on this form are complete and accurate to the best of my knowledge and the services described

have been received.

____________________________________________________________________________________

____________________

Insured Signature

Date

__________________________________________

______________________________________________________________

Phone No.

E-mail

AGLC105137 Rev0714

Aglc105137 - Preventive Care Benefit Claim Form