Form Bn-451-Afes - Individual Cancer, Intensive Care Or Dread Disease Benefit Statement

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INDIVIDUAL CANCER, INTENSIVE CARE OR DREAD DISEASE BENEFIT STATEMENT

AMERICAN FIDELITY ASSURANCE COMPANY

ATTN: Benefit Department

Local Phone # 523-5025

P.O. Box 25160

Toll Free #

1-800-662-1113

Oklahoma City, OK 73125

Fax #

1-800-818-3453

Warning: 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 may be guilty of insurance fraud and subject to criminal and civil penalties.

INSTRUCTIONS TO INSURED

1. Complete STATEMENT OF INSURED.

3. Have physician complete ATTENDING PHYSICIAN’S STATEMENT.

2. Attach ITEMIZED BILLS.

4. If claim is for CANCER BENEFIT, include PATHOLOGIST’S REPORT.

STATEMENT OF INSURED

1. FULL NAME _____________________________________ Date of Birth_____/_____/ ____ Account No. ______________________________

(Please Print

(Last)

(First)

(M.I.)

(Mo)

(Day)

(YR)

Social Sec. # _____________________________

2. Address ____________________________________________________________________________________________________________

(Street)

(City)

(State)

(Zip Code)

3. Telephone number Work _________________________ Home ___________________

4. If claim is for dependent, give name of dependent___________________________ Relationship______________ Date of Birth: _____________

Day

5. For dependent child between 21-25 years of age:

School _________________________________________________________________ Hours Enrolled: ______________________________

Address of School: ___________________________________________________________________________________________________

ID number or Social Security number of student: ____________________________________________________________________________

Is this claim for

Cancer Benefits

Intensive Care Benefits

Dread Disease Benefits

6. Illness Condition _________________________________

7. Has this condition caused previous trouble?_________________________ If so, when? ___________

8. Date first treated _________________________________

9. Have you been confined to a hospital?

Yes

If yes, when From:_________________________ To: ________________________

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

I hereby authorize the entities specified below to disclose any information about me or my dependents’ health including my or my dependents’ entire medical record and history of

treatment for physical and/or emotional illness to include psychological testing, except psychotherapy notes, to individuals representing American Fidelity Assurance Company (AFAC)

who are involved in determining whether I am eligible for benefits under my insurance coverage. Those so authorized are: a) licensed physicians or medical practitioners; b) hospitals,

clinics or medically-related facilities; c) health plans; d) Veteran’s Administration; e) past or present employers; f) pharmacy; g) insurance companies; h) the Social Security Administration;

i) retirement systems; j) Department of Motor Vehicles, and k) Workers’ Compensation Carrier. Colorado state law prohibits the redisclosure or reuse of information disclosed about a

Colorado resident under this authorization.

NOTICE: Information authorized for release may include information on communicable or venereal diseases such as hepatitis, syphilis, gonorrhea, HIV/AIDS (Human Immunodeficiency

Virus/Acquired Immune Deficiency Syndrome) or other conditions for which you may have been treated. For Maine residents, information authorized for release may include information

on communicable or venereal diseases such as hepatitis, syphilis, gonorrhea, AIDS/ARC (Acquired Immune Deficiency Syndrome /AIDS Related Complex) or other conditions for

which you may have been treated. This authorization excludes disclosure of the result of a test for HIV if you have tested HIV positive but have not developed symptoms of the disease

AIDS. Such test results shall not be discovered or published. Nothing in this caveat will prohibit this authorization from including the fact that you have AIDS. For Vermont residents, this

authorization does not require disclosure of prior HIV-related tests. For Wisconsin residents, results of AIDS/HIV test do not need to be reported if they were done at any anonymous

counseling and testing site, if the test was not an FDA-licensed blood test, or through the use of a home test kit. For Arizona residents, release of HIV/AIDS-related information can only be

disclosed for a period not to exceed 180 days from the date shown below.

I understand that I may refuse to sign this authorization; however, if I do not sign the authorization, my failure to sign the authorization may result in a denial or a delay of

benefits. I understand that I may revoke this authorization at any time by writing to AFES Benefits Department, PO Box 25160, Oklahoma City, OK 73125-0160 or by calling, toll-free,

1-800-662-1113. I understand that my right to revoke this authorization is limited to the extent that: AFAC has taken action in reliance on the authorization; or, the law provides AFAC with

the right to contest my insurance coverage or a claim under my insurance coverage. A copy of this authorization will be as valid as the original.

I understand that if protected health information is disclosed to a person or organization that is not required to comply with federal privacy regulations, the information may be redisclosed

and no longer protected by the federal privacy regulations.

For health insurance coverage this authorization will expire twenty-four months from the date it is signed or upon termination of my insurance policy, whichever occurs first. For insurance

coverage other than health insurance, this authorization will expire twenty-four months from the date it is signed or upon expiration of my claim for benefits, whichever occurs first.

Signature (Patient) or Personal Representative (if applicable)

Printed Name (Patient)

Date of Birth

Date Signed

I certify this information is true and correct.

Relationship of Personal Representative to Patient _____________________________________________________________________________________________________________

If authorization is supplied by a personal representative, a description of the authority to act on behalf of the Insured must be included.

Please retain a copy for your personal records, or you may request a copy from our Company.

BN-451-AFES (1007)