Fillable Colonial Life Health/wellness Screening Claim Form

Colonial Life Health/wellness Screening Claim Form - 2015

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Colonial Life | HEALTH/WELLNESS SCREENING | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368

Health/Wellness Screening Claim

FAX this form: 1-800-880-9325

From:

Or mail: P.O. Box 100195, Columbia, SC 29202

FAX this direction

Number of pages:

Optional Service Release Agreement

Please indicate below for optional services you desire. Any marks used (check mark, X, initials, etc.) will be considered as

your authorization and will be processed as if they were selected.

I authorize Colonial Life to facilitate processing this claim by releasing its details to the following individual inquiring on my behalf.

Note: Leave blank if you do not want anyone accessing your claim information.

______ Sales representative ______ Employer ______ Spouse, family member or significant other Name: _________________________

______ I want Colonial Life to update me on the status of my claim through electronic messaging at my contact number indicated on this form.

I understand that messages will be left with anyone who answers the phone or on my answering machine. Note: To avoid blocked

calls, you should program the number 1-800-325-4368 into your phone.

Complete each section before submitting your claim. Incomplete claim form submission may result in a delay in the processing of your claim.

n If your name has changed, attach a copy of your

n Benefits are payable to you unless we receive written authorization to pay them

driver’s license or other legal documentation.

elsewhere. This is called an assignment.

n Dates should be written in month/day/year format

n If this claim is for an individual covered by Medicaid, most non-disability benefits are

(i.e. 12/14/1980).

automatically assigned according to state regulations. This means we must pay the

n Social Security number is indicated by SSN.

benefits to Medicaid or to the medical provider to reduce the charges billed to Medicaid.

–

Section 1

Claimant statement

(completed by policy owner)

Claimant name:

SSN:

£ Male £ Female

DOB: ____ /____ /______

Relationship to policy owner: £ Self £ Spouse £ Domestic partner £ Dependent

Policy owner information

Name:

SSN:

(if other than claimant)

DOB: ____ /____ /______

Address:

City:

State:

ZIP:

Email:

Contact number:

Physician/Treating facility:

Telephone:

Address:

City:

State:

ZIP:

Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. |

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Colonial Life Health/wellness Screening Claim Form - 2015

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