Form Abj16689 - Outpatient Physician'S Treatment Claim Form And Instructions

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CLAIM FORM AND INSTRUCTIONS
If you have any questions regarding benefits available, or how to file 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
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.
OUTPATIENT PHYSICIAN’S TREATMENT CLAIM FORM
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 1-866-424-8482
POLICYHOLDER / CERTIFICATEHOLDER INFORMATION
POLICY NUMBER(s): 1)
2)
3)
POLICYHOLDER INFORMATION:
First Name: __________________________________________ MI: ________ Last Name: __________________________________________
Social Security Number: ________________________________ Date of Birth: _____/_____/_____
Age: ________
Male
Female
Mailing Address:
_________________________________________________________________________
Apt#: __________
Check here if
City: ________________________________________________ State: ________________
Zip: ___________
address is new
Phone #:(____)_________________
E-mail:
PATIENT’S INFORMATION:
First Name: __________________________________________ MI: ________ Last Name: __________________________________________
Social Security Number: ________________________________ Date of Birth: _____/_____/_____
Age: ________
□ Male
□ Female
Relation to Insured:
Self
Spouse
Child
Other
OUTPATIENT PHYSICIAN’S TREATMENT BENEFIT
The benefit described below is available for Outpatient Physician’s
Treatment. Please attach the required documentation requested. If additional information is needed, you will be notified.
Outpatient Physician’s Treatment
REQUIRED DOCUMENTATION: Please provide the following:
Benefit
Provider Name:
____________________________________________
Benefit: 2 visits per person per calendar
Provider Address:
__________________________________________________
year; 4 visits maximum per family per
calendar year.
__________________________________________________
The outpatient physician treatment may
Date(s) of service
and
:
_____/_____/_____
_____/_____/_____
be provided for a sickness, accident, well
exam, physical exam, eye exam or dental
Please attach a copy of a bill or documentation of treatment provided by a
exam performed by a physician outside
physician, outside of the hospital.
of the hospital.
ASSIGNMENT OF BENEFITS
(n/a in New Hampshire)
I request that American Heritage Life Insurance Company send benefits to someone other than me. Please send available benefits to the
name and address shown below. PLEASE BE ADVISED THAT IF YOU ARE COVERED BY MEDICAID, WE MAY BE REQUIRED TO ASSIGN
BENEFITS (except disability) TO THE PROVIDER OF SERVICE IN ACCORDANCE WITH STATE AND FEDERAL REGULATIONS.
____________________________________________
__________________________________________________
Name
Address
___________________________________________
__________________________________________________
Provider’s Tax Identification Number:
City
State
Zip
_____/_____/_____
___________________________________________
___________________________________
Relationship
Signature of Policy Owner
Date
CERTIFICATION:
Please read and sign below
I acknowledge the receipt of the Department of Insurance Claim Fraud Statements provided with this claim packet. I have read the notices and I am
aware that it is a crime to fill out this form with facts I know are false or to leave out facts I know are relevant and important. I certify that the answers
given on this claim form are true, complete, and correctly recorded. In order to process your claim, sign and date the authorization on the
following page.
Date: _____/_____/_____
:___________________________________
: ________________________________
Signature
Print Name
ABJ16689
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