Request For Individual Cancer, Intensive Care Or Dread Disease Benefits Form Page 4
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4American Fidelity Assurance Company
REQUEST FOR INDIVIDUAL
Mail to: AWD Benefits Department
CANCER, INTENSIVE CARE OR
P.O. Box 268898 | Oklahoma City, OK 73126-8898
Toll Free Phone # 1-800-437-1011
DREAD DISEASE BENEFITS
Local Fax # (405)-523-5762
Toll Free Fax # 1-888-243-3453
ATTENDING PHYSICIAN’S STATEMENT
1. Patient’s Name _____________________________________________________________ Age ________ Date of Birth __________
Social Security Number _________________________________________________________________________________________
2. Diagnosis _______________________________________________________________________________ (ICDA Code) _________
3. When did symptoms first appear? ___________________________________________________ Date _________________________
4. When did patient first consult you for this condition? _____________________________________ Date _________________________
5. Has patient ever had same or similar condition? q Yes
q No (If “Yes,” state when and describe)
____________________________________________________________________________________________________________
6. Was patient referred to you by another physician? q Yes
q No (If “Yes,” list name and address of referring physician)
Name __________________________________________________________ Address _____________________________________
7. If patient hospitalized, give name and address of hospital ______________________________________________________________
Admit Date ______________________ Discharge Date _______________________
Date ____________________________ Signed _____________________________________________________________________
Degree
____________________________________________________________________________________________________________
(Street Address)
(City or Town)
(State)
(Zip Code)
Tax ID Number _______________________________
If your claim is for a cancer diagnosis, we must have a copy of the PATHOLOGY REPORT from the FIRST PROCEDURE in which
cancer was diagnosed before any benefits can be provided. Your oncologist or your primary treating physician should be able to
furnish you with a copy of this report.
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BN-451-AWD(VT)-1011
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