Form Abj10367-1 - Wellness Claim Form - 2012

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WELLNESS CLAIM FORM
If you have any questions regarding our determination of your claim, or if you would like to
appeal any determination, please contact our Customer Care Center at 1-800-348-4489
8:00 A.M. to 8:00 P.M. Eastern Standard Time.
Claim forms and other valuable information may be found on
The furnishing of this form, or its acceptance by the Company as proof, must not be construed as an admission of any
liability on the part of the Company, nor a waiver of any of the conditions of the insurance contract.
POLICYHOLDER / CERTIFICATEHOLDER
 Male  Female
Insured’s Name:
Patient:
Policy Number(s): 1)
2)
Insured’s Social Security Number:
Patient’s Date of Birth:
/
/
MO/DAY/YR
Home Number: (
)
E-mail:
Filing a claim for your calendar year Wellness Benefit is easy! If you have had one of the listed preventative tests
or HPV Vaccination shown below, please check the appropriate boxes and attach any documentation you may
have showing the provider, patient’s name, the date of the test, and exam performed. If your policy was issued in
Pennsylvania or California, please send us the actual bill and the Explanation of Benefits from your Major
Medical Carrier.
Thank you for selecting Allstate Benefits and for having your annual wellness exam!
WELLNESS SCREENINGS
 Biopsy for skin cancer
 Flexible sigmoidoscopy
 Blood test for triglycerides
 Hemocult stool analysis
 Bone Marrow Testing
 HPV (Human Papillomavirus) Vaccination
 CA125 (cancer antigen 125 - blood test for ovarian
 Lipid Panel (total cholesterol count)
cancer)
 CA15-3 (cancer antigen 15-3 - blood test for breast
 Mammography, including Breast Ultrasound
cancer)
 CEA (carcinoembryonic antigen – blood test for colon
 Pap Smear, including ThinPrep Pap Test
cancer)
 PSA (prostate specific antigen – blood test for prostate
 Chest X-ray
cancer)
 Colonoscopy
 Serum Protein Electrophoresis (test for myeloma)
 Doppler screening for carotids
 Stress test on bike or treadmill
 Doppler screening for peripheral vascular disease
 Thermography
 Ultrasound screening of the abdominal aorta for abdominal
 Echocardiogram
aortic aneurysms
 EKG (Electrocardiogram)
ASSIGNMENT OF BENEFITS FOR WELLNESS COVERAGE (n/a in New Hampshire)
I request that American Heritage Life Insurance Company send benefits to someone other than me. Please send benefits available to the name and
address shown below:
Name
Address
City
State
Zip
Provider’s Tax Identification Number
Relationship
Signature of Policy Owner
Date
You may mail or fax your claim to:
American Heritage Life Insurance Company
1776 American Heritage Life Drive, Jacksonville, FL 32224
Phone 1-800-348-4489
Fax 1-800-430-4188
ABJ10367-1
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