aflac disability form

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In addition, please read and then sign the Authorization for Disclosure of Health Information (HIPAA form) included in Part A, as well as the separate Authorization for Disclosure of Health Information (HIPAA form). /Type /Font ["`,abhS3LE"C=T6]&k%"Zl4BdN^JG3F!Y*CQe"Xqj- 15 0 obj endobj >> Claimsmaybefaxedto1-877-44-AFLAC(1-877-442-3522) NY-S00224NY Page2of3 02/14 *LastName Suffix *FirstName MI *DateofBirth(mm/dd/yy) *Employee'sName(LastName,Suffix,FirstName,MI) *Employer'sName/Account# *Employer'sPhoneNumber INITIALDISABILITYCLAIMFORM-EMPLOYER'SSTATEMENT EMPLOYER'SSIGNATURE EMPLOYER'SPRINTEDNAME TITLE DIRECTPHONENUMBER DATE IulVik4tYO+5Y]5dC6+if#]pW>?S#%PB"2$kEPR@U_!W)J++r5@@21spCE@V_m\2SM=jcqaH.-P9&U%f !G5'>m!$kI`%E,=&c9e1!`-(ln6%1Abq7/PK2;m`V,'D51([Fj 0000000326 00000 n << /Count 1 /First 18 0 R /Last 18 0 R >> :6M_J^sl@Y"on\+c])/C^-146>Nm%4SY-!+ME-(F2p8]9b1! 0000000814 00000 n !ncB:\VKdEm`qT:*N=[JNN2d(=N=eQCP0@YV._+qhu3A\"7SbVdlGbB#r@F8W,NFT7X_+Li_!4M/4=!o 20 0 obj )toiFe(5W*JmS'IeRpMhRM\E^RfC)>n7:/sPgsY5E^.`.P>\/9SK;2 93^8SlqmQZ!1De"\u*GfeLd;np?nPWYSd67)d]ch=uD%XiFi:dZhC'MhDK8OlZ2*YHmB.O$)Wh[*"R,, %PDF Font (F38) POije23\6G%qCTitHV>Xor, 8;U4*8AZ=@b:l^dJ*L_0.&7i0E^jm_'-W Select the Get form button to open the document and move to editing. endobj a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. 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Aflac promised to be here when you need us most - and a big part of that promise is making the claims process easy. ?&2QmV4C.$NuL;0P(Z7tk6M Yku1YRdk^9;TD\;*kl4jYjTa8Xl"SC:fUS)e;!AcrDK#l16`LFaGhEJ;`,G>'H*8^Jr\^>/E?FZ]1S?b Please submit required medical documentation for the specific covered critical illness, the claimant's birth certificate, a list of the names of all doctors and hospitals in the appropriate section, as well as a signed and dated Authorization for Disclosure of Health Information (HIPAA form). * endobj <> /XObject << stream 16 0 obj 0000049255 00000 n endobj Bk\1f/VUX4ST4NT40lN34+-*[pI_iW#ggd2*`hgWE^=-R:s=)2'tu01Vr]^_S>-&.RS7)o+'X@(Y83/( h0cQ^!FY^@5YZ9`C((MZ9iSNHc>@i(/A6Ang=Q>29[%f,N\.ZX(j>Mqs0Q)QK[VqWr`O1c][Ae6 26 0 obj nBr?OjbmGB*-+c"Gfs=pq`pf\5/qG=9-4ag[=%5G2c]U@?7%qhqm. 24 0 obj "iE5=j8``/gXCMXF TiH!-bXfof5[n@&[kS/JgZ:HFlTDHBWer?faRZL endstream S`*[trI8jg7M]JT\+.`38%i%%!hk`4S6H:;p^t(C%5sr,][Cckok`Lt\9"4E`IkRu$'/ai^g,u(4jLe=m[4V59--p2Tap(*UC^8Qur;jVC%5c7VaBB+,0AUKH@dUPF5MD >> 2&Tk-bp^c+fLgI$.,d5^! <> endstream endstream 44EBCGZWK1$09&Q#o?-4-.oof+30H,2'QUFu;$7Pkc '1L#-Ne#BOUYn.SL> a*7QP2nR!.R_;hRHWlnl#NqY`2;1A,B&CcHbipl%. 16 0 obj 3 0 obj Please provide all information requested on the Insured's Statement portion of the claim form. 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Submit or View Your Claim >> Aflac Continuing Short Term Disability Claim Form Initial Disability Claim Form https://www.nova.edu/hr/benefits/forms/aflacdisability2017.pdf Please note: The employer is required to report disability benefits paid on pre-tax plans on Form 941 and the employee's Form W-2. endobj <> And the best part? 0000001422 00000 n <> startxref (V.ea8oM1meVG5&2$R&VHdRmbM`,/jQ'iTTlk_NLi7Pu8>hqB>F6,at#]$=1\UL'_o ?f48_G,BN0p=/>&*)"gUTVU[Y>F[!H0S$cH]UJRYpFnh6'Ae"7a6i,,,Lbtk3(JMM]r0XUgZr>L@0I'i C)U\u?j:;&T7I/iGm[n\T;_)`gEYqdm*YLN@N-_eg4^hU\]H7Co2_+ugag&:Fd?U>McjOT-(PdfS7Ma7 << /Count 1 /First 18 0 R /Last 18 0 R >> Get rid of the routine and create paperwork on the web! A BenExtend claim requires supporting documentation for review of benefits such as an itemized bill if there was a hospital stay, itemized bill from physician's office, surgical report if surgery took place, Xray/Diagnostic Test reports with dates and charges if applicable, accident report if applicable, and a signed and dated Authorization for Disclosure of Health Information (HIPAA form). X3^f``c_A)\*/"78h!p%/*in2gI^?CblC`0:Dk,=U@Ip$RaFkC-A%5t[ObE/d?Sc8c!X5%k0qkA1$A(f 25 0 obj $d*luDgu%=_)ZTRYN*[j%c5i9etXm(3c;IaR;/mP`e'Y8+An%3f-4Yl=is#36K Learn more claim-forms - Georgia Department of Administrative Services D3IFAAEDU]W&`=8ZQHFkEqDQ^[Kaa=!=[XM/$T#Eb_7Ual%dq@k@o8>[email protected]<0#6L^ZrQRcYr_T "D=hF9Hc;3b+uU#87#u->Oo&ZR/kmg`A@Va9ssE1`$L205UY2\m1KJ?'g1*p?gL[/Z6a.dV! m^PaP#$T,QfVQ'7kTb=#ja*O^[oT:q1qW?WH%a_Lp. :0&HC(d$*r1.Y<=jD`$Ia7bVR3*X"Pd8ODQ(-pM4B8oHgR Direct to Consumer individual coverage underwritten by Tier One Insurance Company. FuFfnc;)7cKg['Zqu$@#^.Lm;P)OIh\R^_`-@):D`Br-$pdOd.\.5Vk2j_jL6C'[%-[(4 Aflac Short-Term Disability Insurance pays cash benefits for covered disabilities (subject to exclusions and limitations). <> TLFC\4aS)n5C^j*@4%"P0VVa9rj(. 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P;j%5)jo)E)Oa&qP(Ph7/Yj! @mT@XKG9gfV9sjgJ:!#'gnJe-hrK2RiqoM==]mG(t!Vd6O=URG3 >> )_uYFAPMnh@@qLR(!tj0,JgDV:^2aU1j,Q1G5%+A&.^pn]C"PJA:oAllMYj0psPAVZ_E,8iGS^\I&;A'/E"CXIR`WpK_.^,?uB7C2c/q!Ft;r%bq\)j#XX/c~> endstream Aflac is here to help. ;PmE,29/@]Q_gjie3>F*fbNG$7H6^5^trSgt@MX18^JE+B$K 0000001020 00000 n POije23\6G%qCTitHV>Xor, e(d`r+1(IK_Z9J8FZEKhh]p"mOP2o\*_i:B,oR:q;pr&)1JfnGrF_2WN1&RdVP7b@X=`\9QI&,k/0N4e 0 27 nhH(@HB3(k..$A&2I&hNumCF[&]PjI*`R_D2M6]X>#-E#f;915&(PF6%>9Knd"E.:PO 3OKN&2W(XWj*4Pa1H50U%qWra$*VdVbd3"%Mqma1p?g8L8>2.+8'p^s14V/euOX@S5` U;s(7Es'Hq&:@a]^0oUGCJa3R7thK`//"XdS%5f,bl:[\>V0EGJX9:R[P$&(L2fO4E"!r*bnZA.0JbrSKY5@2H. 0000043584 00000 n 14 0 obj h.*.:`/`($FjUjeMh+%3^KDbf? h/#o:*lSpdqlZg*XqFsNY5T/YFk%>_'?0&0X0BaP:*/_(BP1Z\9IQQ3"3LWkO02ijH;rAcRPahK(DRaJ $#%T)fK!\tQ[Jn*RsIK/pH_*8DKaR?SCRR(r\bkG)d0WRf`3S_ZkZBKR^5r=EJjF/IhU)M'c/^18tpgR )_uYFAPMnh@@qLR(!tj0,JgDV:^2aU1j,Q1G5%+A&.^pn]C"PJA:oAllMYj0psPAVZ_E,8iGS^\I&;A'/E"CXIR`WpK_.^,?uB7C2c/q!Ft;r%bq\)j#XX/c~> ii0)@:9O(%@H%RrdWERj>N3*\BUO1i]tqg3/1[H/;eAHS(@In[U#O`g'CB(1Z@f9[-o$S-AZ%3&Ipb== (!XZ[fVqDrg=%mnL@dD71:nKqKueQnUtLi;)rD"M-*:ia#uT*5f$!AicdVn^"gp(^-oKqo#i"gBOsIn1fK.\PJgLt&^imq7BSJ..gu`g3TNp]lZQ:Q+PSQZ=7bSOhN`;B#7;s#7r)aO+XB?-BFdCkA(+.VnQp*5O$?iSK/`O.QJ'S)/aPDmhO:I1AIuZ^Ves%d@6'UQ5gRhf3BF`kXpaej\IRil\Y_Tp',^\5b3DiW.2X/9G,ZBZNQ1%0jnNTP=-/t4]pG5O*!$Hj%$(Vi!33gU7QS]rt"S4I%1~> ^$F!_M^D.n0(qARn(aE/AgY,iIM9"8CcNDqjSN*8m)"[email protected]==Xc1]GcbA-_LZ\:A:pe2tj Please provide a certified copy of the deceased person's birth certificate and death certificate. Ro:8N4Fo0263Y9=VZCO2ZaPKP*j"-CFnE=:3h#1r A&!R^maAJpBZW3)>! 0000040092 00000 n ?M?uK\`[L'MVpgq.\;DFhc?I3,E@L<5O.H'In/5-%oHIk6Y].-91Vsi8;^S7T-@bW-s/Y'OlKTsB7_NY 15THsJWlVj?FW\)knqP*Lk! "Jk(XbKsV#$D'i]&;mcIV!r ["`,abhS3LE"C=T6]&k%"Zl4BdN^JG3F!Y*CQe"Xqj- 10 0 obj p!WHg/S/1>qh13::;;66rN. @lR;bed"/KM4=.N)6,FfJ&AfVrJm-US :JP2npQHaeod^X7'sK!^CIY561O?2S)MJ3_5]Y=4,Cn7b%K5Me(p[?9MOo\lj=] Get filing requirements, supporting documentation details, and more. If your disability is being extended, you will need to complete the listed Supplemental Claim form. 0000000009 00000 n 0000000212 00000 n 0000055045 00000 n O!61!%9G.V^/"+$60K[1j:%8%V^jr#WgA)E0dmgaHYP)uTIcfaXm(sZ9L'dZ;nA@OpWjJ1,O,)*$t/$< Gb"/l>AkOk&]_Z/^,64CCgQh(QQim(`'@6(M1VCS?Ymokm)Y?"923o3hrP9g4Yu*CcB6B*!?;6YT@s1*_r:*jjIVWN?8SPT[V>.M20U,P9l'4iI6TPY-]L!#f3%M(`,YCfUG&+3=,h@oh'%%R8_;#D97$7DPAU-\'4cMbSmaD1quDo:PhC8FAQ_/2XZE4Kg#d',UPm7ke>cGNcuWsA1Re6L<8TPh=9[*Pk3kf]HG?:]j+f^e0da8lF5rcV:E%B=r3G;%R(Xf":ZPhD;HI=o2=W1:skhAOSf)4$6[Y*hA_qQ>#XK+S'ZUkOIKD*iLBqMO1XS"!cLPYd()UE9Lm2lr6Mn03Uc=D9cmg9ZFLR'j#lTAS?p0fFMITB#ShK:pcr`bu\*p_7fncO=H:Cg))Dh,V>4bK>oW$PT7aee,0TKjD0nWW>XIsXWdMeY)H^W"J?KP[.,0T5VP[&"V-R*m\g;oH$Xg-3^E`2UO>b:S!S#%Ni>r1U>7W]WVl%FBJ6EJLK\e5S/p'%Rhg`ig(XQcq,`dM"Z"a`kcZ-'(jE_+^$?7s6^cGj474dI*df2J-e5q=Y_1b16H?P]03X?3K>qnsh^!G`9eSL__s6U1M*9Teo45)s'E#TeBH)kV0Og)S^AO+J(2F[da5RA>ICW7:^P&t'LLAnd0HKr&IpsIn8SeU(:Jc=*pS?k-99YCErn>UJX-`Hn%(aqln*&$XIcANS4VpU[QLj]G!;#@EAKq^@j,u;`/,(/Na!g5q"Yh65\"D,!aB.Em\'n/8"7*<31JeCqa`mMJ:h^-@Y+&*%Hi'pHjq[(V+Huac?`=P/n;ZtVYhK&jU4+P;,;Li0RY7*b9.,B=i>Eeq&&>XEt+0g%csST^gUX`O)f4L?@mpN=*2KGID@n!ahWqW<0.bbeua0:q(o7]2r0OVPUZgknmZaeqoclXGYUp'!2bS=sHp[\G[PG!Smtge^H`:p@^73,cnK$pco"N52fZ7k,?t_TBa6[Yo38a*bPjO'L>&jO>C.hg#O#*qQR%MfmPB/pb=.ds3hbk[@d1B`!QLOun.$sgs3XfN'9kHM]j^-B:=S5hBb`)3Y[+?"%4"O*G7.WL:[M7VEor0!>;%F[GQFZUW-817ADTaR](EM)4B>C4br^N)Q@KkkpNbQ$O`Ai!OQG#u9I'pD\EjH. 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aflac disability form