Statement Of Policyholder - Diagnostic Testing Benefit
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1INDIVIDUAL CANCER DIAGNOSTIC BENEFITS STATEMENT
RETURN THIS BENEFIT FORM AND ATTACHMENTS TO:
AMERICAN FIDELITY ASSURANCE COMPANY
American Fidelity Educational Services
ATTN: BENEFITS DEPARTMENT
Toll Free #
(800) 662-1113
P.O. BOx 25160
(800) 818-3453
Fax Toll Free #
OkLAHOMA CITY, Ok 73125
(405) 523-5025
Local #
STATEMENT OF POLICYHOLDER
DIAGNOSTIC TESTING BENEFIT
1)
Patient’s Name: ________________________________________________________________________________________________________
2)
Relationship to Policyholder: q Self
Spouse
Child
q
q
Patient’s Date of Birth: ______________________________________ q
Male
Female
3)
q
For dependent children between 21-25 years of age please provide
4)
School Name: _________________________________________________________________________________________________________
If a full time student, please enclose a copy of transcript
5)
Policyholder’s Name: ____________________________________________________________________________________________________
6)
Cancer policy number (account no.) _____________________________ or Social Security number of policyholder _________________ ________ .
7)
Street Address: ________________________________________________________________________________________________________
q Check if address has changed
City, State, Zip: __________________________________________________
Telephone Number: ______________/______________/______________
PLEASE ATTACH BILL, RECEIPT OR EVIDENCE OF THE TEST.
Be sure to include your account number or Social Security number on all documents.
Warning: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim containing any false,
incomplete, or misleading information may be guilty of insurance fraud and subject to criminal and civil penalties.
For Residents of California
Warning: For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent
claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
For Residents of Pennsylvania:
Warning: Any person who knowingly and with intent to defraud any insurance company or other people files an application for insurance or
statment of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
For Residents of Florida:
Warning: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing
any false, incomplete, or misleading information is guilty of a felony of the third degree.
For Residents of Arizona:
Warning: For your protection, Arizona law requires the following statement to appear on this form: Any person who knowingly presents a false or
fraudulent claim for payment of a loss is subject to criminal and civil penalties.
BN-672 (0507)
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Parent category: Medical