Fillable Colonial Life Health/wellness Screening Claim Form

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

Policy owner name:

Policy owner SSN:

If other than policy owner

Claimant name:

Claimant SSN:

Type of screening test performed — complete one claim form for each claimant for each calendar year

You must attach a copy of the bill(s) for each test. The bill(s) must include the facility/physician’s name and telephone number.

Review your policy or policies for the list of covered tests prior to completing this form.

Health/wellness screening benefit is NOT payable for routine physical examinations.

Most policies provide one health/wellness screening benefit per calendar year (refer to your policy for details).

Fill in the date of the test you had performed below.

TEST

DATE (MM/DD/YYYY)

Blood glucose

Electrocardiogram (EKG/ECG)

_____ /_____ /_____

Bone marrow aspirate/biopsy

Hemoccult stool analysis

_____ /_____ /_____

Breast ultrasound

Mammogram (breast)

_____ /_____ /_____

CA125 (ovarian cancer)

Pap smear/thin prep pap (GYN)

_____ /_____ /_____

CA 15-3 (breast cancer)

PSA (prostate)

_____ /_____ /_____

Cancer vaccine

Serum protein (myeloma)

_____ /_____ /_____

Carotid Doppler

Skin biopsy

_____ /_____ /_____

CEA (colon cancer)

Sigmoidoscopy

_____ /_____ /_____

Cholesterol (HDL /LDL /lipids)

Stress test (bicycle/treadmill)

_____ /_____ /_____

Chest X-ray

Thermography

_____ /_____ /_____

Colonoscopy

Triglycerides

_____ /_____ /_____

Echocardiogram (Echo)

_____ /_____ /_____

Certification

Policy owner’s name:

SSN:

_________________________________________________________________________

_________________________

I have checked the answers on this claim form, and they are correct. I certify under penalty of perjury that my correct Social Security number is shown

on this form. I acknowledge that I received the Claim Fraud Statements on page two of this form and that I read the statement required by the State

Fraud Warning: Any person who knowingly and with intent to

Department of Insurance for my state, if my state was listed on the form.

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.

____________________________________________________

______________________________

Print claimant’s name

Claimant’s signature

Date

(MM/DD/YYYY)

____________________________________________________

______________________________

Print policy owner’s name

Policy owner’s signature

Date

(MM/DD/YYYY)

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 Page 3

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