Express Wellness Benefit Claim Form Page 2
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EXPRESS WELLNESS BENEFIT CLAIM FORM
The Benefits Center
Coverage Effective Date (mm/dd/yy)
P.O. Box 100158, Columbia, SC 29202-3158
_____________________________
Toll-free: 1-800-635-5597 Fax: 1-800-447-2498
Product: GCI, GACC, GHI
Call toll-free Monday through Friday, 8 a.m. to 8 p.m. Eastern Time.
INSURED/PATIENT STATEMENT (PLEASE PRINT)
A. Information About the Insured
Last Name
Suffix
First Name
MI
Date of Birth (mm/dd/yy)
Social Security Number
Gender
o Male
o Female
Home Address
City
State
Zip
-
Home Telephone Number
Cellular Telephone Number
Work Telephone Number
Policy Number(s)
Preferred e-mail address
B. Information About the Patient - Check One o Self o Spouse o Domestic Partner o Child
Last Name
Suffix
First Name
MI
Date of Birth (mm/dd/yy)
Social Security Number
Gender
o Male
o Female
Home Address
City
State
Zip
-
C. Information About Your or the Patient’s Express Wellness Benefit Claim Complete this section for Express Wellness Benefit claims. Please note: If you are
submitting this claim request 2 years or more after the date of the test/x-ray, please attach written documentation verifying the date the test/x-ray was performed.
Please check only one test for this patient and indicate the date the test was performed.
Test
Test Date
Test
Test Date
Test
Test Date
o Blood Test for Triglycerides
_____________
o Electrocardiogram
_____________
o Serum Cholesterol Test to
o Bone Marrow Aspiration/Biopsy
_____________
o Fasting Blood Glucose Test
_____________
Determine Level of HDL and LDL _____________
o Breast Ultrasound
_____________
o Fasting Plasma Glucose (FPG)
_____________
o Serum Protein Electrophoresis
o CA 15-3 (Blood Test for Breast
o Two Hour Post-Load Plasma
(blood test for myeloma)
_____________
Cancer)
_____________
Glucose (2 Hour PG)
_____________
o Serum Protein Test to Determine
o CA 125 (Blood Test for Ovarian
o Hemoglobin A1C (HbA1c)
_____________
Level of HDL and LDL
_____________
Cancer)
_____________
o Flexible Sigmoidoscopy
_____________
o Skin Cancer Biopsy
_____________
o CEA (Blood Test for Colon Cancer) ____________
o Hemocult Stool Analysis
_____________
o Stress Test on Bicycle or Treadmill _____________
o Carotid Doppler
____________
o Mammography
_____________
o Skin Cancer Biopsy
_____________
o Chest X-Ray
____________
o Pap Smear
_____________
o Thermography
_____________
o Colonoscopy
____________
o PSA (Blood Test for Prostate
o Thin Prep Pap Test
_____________
o Echocardiogram
____________
Cancer)
_____________
o Virtual Colonoscopy
_____________
o __________________________ _____________
D. Tax Considerations
Benefit payments under this policy could be considered taxable income to the extent you pay premiums on a pre-tax basis or your employer pays premiums with-
out including them in your income. Unum reports taxable income to you and the IRS as required on form 1099-MISC. Every tax situation is unique. You should
seek independent advice if you have questions about your personal tax situation.
E. Signature of Insured
I have read and understand the fraud notices listed on pages 3 and 4 of this form.
The above statements are true and complete to the best of my knowledge and belief. (Your signature is required for benefit consideration.)
X
___________________________________________________________________________________
______________________________________
Signature
Date
I signed on behalf of the insured, as ____________________________ (indicate relationship). If Power of Attorney, Guardian or Conservator, please attach a
copy of the document granting authority.
CL-1144 (08/14)
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