Fillable Spousal Disability Rider Claim Form (Page 2 of 4) in pdf

ATTN: AWD BENEFITS DEPT.

P.O. Box 268898

REQUEST FOR SPOUSAL

Oklahoma City, Oklahoma 73126

DISABILITY RIDER BENEFITS

Toll Free: 1-800-437-1011

Fax: 1-888-243-3453

See page 1 for fraud statements.

SECTION 1- STATEMENT OF INSURED

1. Full Name __________________________________

Date of Birth _____/_____/____ Account No. _____________________________

Please Print

(Last)

(First)

(M.I.)

(Mo)

(Day)

(YR)

2. Address __________________________________________________________________ Social Security No .______________ ____________

(Street)

(City)

(State)

(Zip Code)

3. Telephone number Work __________________________ Home __________________________ Employer ___________________________

SECTION 2- COMPLETE STATEMENT OF SPOUSE

1. Patient Information- Spouse Full Name ______________________________ Spouse SS# ________________ Date of Birth: ______________

Last

First

2. Spouse’s employer _____________________ Address_____________________________________________Telephone # ________________

ccupation:____________________________Has your employment terminated? ______ If so, date: ________________________________

On what date did you last work? __________________________ Dates of total disability: From ______________ _________________________________

Thru _______________________________________________ On what date did you return to work? __________________________________________

Part Time ________/________/________ __________________ Full Time ________/________/________

If not returned to work, when do you anticipate returning to work?___________________________

4. Disabling Accident Condition ___________________________________________________________________________________________

5. Date accident occurred ____________________________

6. Have you been confined to a hospital?

q Yes

q No

7. Have you ever had the same or similar condition in the past?

q Yes

q No

8. If yes, names and addresses of all treating physicians and/or hospitals: ___________________________________________________________

___________________________________________________________________________________________________________________

Date ____________________

Signature _______________________________________________________________ I certify this information is true and correct

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

I hereby authorize the entities specified below to disclose any information about my entire medical record or benefits payable for this disability 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.

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. 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.

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 AWD Benefits Department, PO Box 268898, Oklahoma City, OK 73126 or by calling,

toll-free, 1-800-437-1011. 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 pro-

vides 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)

Relationship of Personal Representative to Patient

Date

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-717(AWD)-0712