ACCIDENTAL INJURY CLAIM FORM
Failure to complete this form in its entirety may result in a delay in processing this claim.
Please answer the following questi ons. The claim cann ot b e processed until all necessary inform atio n i s p rovided:
Date of accident
: ___________ Describe how the accident happened: ________________________________________________
________________________________________________________________________________
Locati on of t he accident ? On the job Off the job Other (please describe): ______________________
Was the patient the driver in a motor vehicle accident? Yes (Attach the police report) No
If the patient sought tr eatment ( 50 /100) or more miles fr om his/her resi dence and requir ed lodging for patient's relative while
the patient was confined in hospital then s ubmit t he hotel receipt(s). Please check your policy t o verify the m ileage your policy covers.
07/08
Page1of2
Patient Information
(Please print.)
Patient Birth Date:
Policyholder Information
(Please print.)
Check box i f t his is a
new permanent address:
Phone Num ber
Social Security Number
Sex:
Male Female
First Name
Initial
Last Name
First Name
Initial
Last Name
City
State
ZIP
Mailing Address
American Family Life Assurance Company of New York (Aflac New York)
Attention: Claims Department • 1932 Wynnt on Road • Columbus, GA 31999-7255
For information or help filing your claim, please call toll-free 1-800-366-3436 or visit our Web site at aflacny.com
Toll-free fax number 1-877-844-0201
Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the
purpose of mis le a ding, information concerning any fact material thereto, commits a fraudulent insurance ac t,
which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated
value of the claim for each such violation.
Relationship:
Prim ary Pol icyholder Spouse
Dependent Child Check here if dependant child is a f ull-time student (if over t he age 19, please provide sc hool nam e and
contact inform ation).
_____________________ ___________________________ ___________
CLAIMANT SIG NATURE FAMILY RELATIONSHI P, IF NOT POLICYHOLDER DATE
NY--S-00198
Complete Policyholder/Patient Information and sign your claim form.
Have the treating physician complete Section B: Physician's Statement and sign the claim form or
If hospit alized and/or confined to an intensive care unit/step-down unit, please send a copy of your hospital bill showing charges and the number of
days you were confined. These items can be obtained directly from y our healthcare provider(s) by requesting a UB04 (hospital bill) or HCFA1500
(non-hospital bill).
If you are filing for disability, please complete the Initial Disability Claim Form (NY-S00224) as well. Forms are available on our web site at
aflacny.com.
Policy Number
ACCIDENTAL INJURY CLAIM FORM – PHYSICIAN'S STATEMENT
Failure to complete this form in its entirety may result in a delay in processing this claim.
Page2of2
07/08
SECTION B: P HYSICIAN'S STATEMENT Please answer each question COMPLETELY.
Physician's Name Phone Number
()
Fax Number
()
Mailing Address City State ZIP
Date of incident: _____/_____/_____ Describe where and how the inci dent occurred:_________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Was the patient referred to you by another physician? Yes No
If yes, physi cian's name: ________________________________________________________________________________________________
Refer ring phy sician's addres s: _______________________________________________________ Phone num ber: _____________________
Was patient hospitalized as a result of this diagnosis ? Yes No
Admis sion: ______/ ______/ ______ Discharge: ______/______/______
Hospital Name: ____________________________________________________________________________________________
City: ____________________________________________________________________________________ State: _________
DATES OF
SERVICE
DIAGNOSIS
CODE ICD
DIAGNOSIS DESCRIPTION PROCEDURE
CODE
PROCEDURE DESCRIPTION
Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the
purpose of mis le a ding, information concerning any fact material thereto, commits a fraudulent insurance ac t,
which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated
value of the claim for each such violation.
PHYSICIAN'S SIGNA TURE DATE TAX ID NUMBER
Policy Number: ____________________________ Policyholder Name: ____________________________________________________
Patient Name: ______________________________________________________ Date of Bi rth: ______________________________________
American Family Life Assurance Company of New York (Aflac New York)
Attention: Claims Department • 1932 Wynnt on Road • Columbus, GA 31999-7255
For information or help filing your claim, please call toll-free 1-800-366-3436 or visit our Web site at aflacny.com
Toll-free fax number 1-877-844-0201
NY--S-00198
Claims Authorization to Obtain Information
Instructions for completing this Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant
form:
1. All areas of this form should be completed.
2. This form must be signed and dated by the claimant/patient below.
3. IMPORTANT: If you are filing a claim on behalf of a deceased, please check here
4. If you are the Authorized Representative, please sign below and indicate your relationship to the
claimant/patient/deceased. In addition, include a copy of the legal document(s) authorizing you to act on their
behalf.
5. Fax this form to 1-877-844-0201 or return the form to Aflac New York, Attn: Claims Department, Worldwide
Headquarters, 1932 Wynnton Road, Columbus, GA 31999-7255 as soon as possible to expedite the review of
your claim.
Policyholder Name:
Policyholder Address:
Claimant/Patient Name (if different from named policyholder listed above):
Name and Address of health care provider(s), company, or individual authorized to release the requested
information:
This authorization shall be valid for a period of two years from the sign date unless a lesser time frame is
indicated. Alternate Expiration Date:
Purpose of Disclosure: Evaluate claims for benefits during the time this authorization is valid.
I, or my authorized representative, request that information regarding my past, present, or future physical or mental health
condition (excluding psychotherapy notes), employment, other insurance coverage, or any other nonmedical facts be
released to American Family Life Assurance Company of New York (Aflac New York) or any person or entity acting
on its part. This could include, but is not limited to, any medical professional, medical care institution, insurer (including
Aflac New York, with respect to other Aflac New York coverages), reinsurer, government agency (including departments of
public safety and motor vehicle departments), consumer reporting agency or employer.
I understand that:
1. Protected health information may include information and records protected under Federal and State Law such as:
alcohol, drug abuse, mental health, AIDS or HIV testing or treatment.
2. My treatment, paym ent or eligibility f or benefits may not be conditioned on signing this authorization.
3. I understand that I may revoke this authorization at any time by writing to Aflac New York, Attn: Claims
Department, Worldwide Headquarters, 1932 Wynnton Road, Columbus, GA 31999-7255, except to the extent
that:
a. Aflac New York has taken action in reliance to this authorization, or
b. Other law provides Aflac New York with the right to contest a claim under the policy or the policy itself.
4. If the requestor or receiver is not a health plan or health care provider, the released information may no longer be
protected by federal privacy regulations and may be redisclosed.
It is recommended I retain a copy of this signed form for my records, understanding that a copy is as valid as the original.
Signature of claimant/patient, guardian or authorized representative Date
Printed name of claimant/patient, guardian or authorized representative Relationship
Policy Number(s): Date of Birth:
Date of Birth:
American Family Life Assurance Company of New York (Aflac New York)
Home Office · 22 Corpora te Woods Boule vard Suite 2 · Alba ny, NY 12211
1.800.366.3436 · aflacny.com
NYS-00216 rev. 7/08
