"Health/Wellness Screening Claim Form - Colonial Life" - South Carolina

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Download "Health/Wellness Screening Claim Form - Colonial Life" - South Carolina

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Colonial Life | HEALTH/WELLNESS SCREENING | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368
Health/Wellness Screening Claim
FAX this form: 1-800-880-9325
From:
Or mail: P.O. Box 100195, Columbia, SC 29202
FAX this direction
Number of pages:
Optional Service Release Agreement
Please indicate below for optional services you desire. Any marks used (check mark, X, initials, etc.) will be considered as
your authorization and will be processed as if they were selected.
I authorize Colonial Life to facilitate processing this claim by releasing its details to the following individual inquiring on my behalf.
Note: Leave blank if you do not want anyone accessing your claim information.
______ Sales representative ______ Employer ______ Spouse, family member or significant other Name: _________________________
______ I want Colonial Life to update me on the status of my claim through electronic messaging at my contact number indicated on this form.
I understand that messages will be left with anyone who answers the phone or on my answering machine. Note: To avoid blocked
calls, you should program the number 1-800-325-4368 into your phone.
Complete each section before submitting your claim. Incomplete claim form submission may result in a delay in the processing of your claim.
n If your name has changed, attach a copy of your
n Benefits are payable to you unless we receive written authorization to pay them
driver’s license or other legal documentation.
elsewhere. This is called an assignment.
n Dates should be written in month/day/year format
n If this claim is for an individual covered by Medicaid, most non-disability benefits are
(i.e. 12/14/1980).
automatically assigned according to state regulations. This means we must pay the
n Social Security number is indicated by SSN.
benefits to Medicaid or to the medical provider to reduce the charges billed to Medicaid.
Section 1
Claimant statement
(completed by policy owner)
Claimant name:
SSN:
£ Male £ Female
DOB: ____ /____ /______
Relationship to policy owner: £ Self £ Spouse £ Domestic partner £ Dependent
Policy owner information
Name:
SSN:
(if other than claimant)
DOB: ____ /____ /______
Address:
City:
State:
ZIP:
Email:
Contact number:
Physician/Treating facility:
Telephone:
Address:
City:
State:
ZIP:
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. |
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| ColonialLife.com | 8-15 | 70067-13
Colonial Life | HEALTH/WELLNESS SCREENING | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368
Health/Wellness Screening Claim
FAX this form: 1-800-880-9325
From:
Or mail: P.O. Box 100195, Columbia, SC 29202
FAX this direction
Number of pages:
Optional Service Release Agreement
Please indicate below for optional services you desire. Any marks used (check mark, X, initials, etc.) will be considered as
your authorization and will be processed as if they were selected.
I authorize Colonial Life to facilitate processing this claim by releasing its details to the following individual inquiring on my behalf.
Note: Leave blank if you do not want anyone accessing your claim information.
______ Sales representative ______ Employer ______ Spouse, family member or significant other Name: _________________________
______ I want Colonial Life to update me on the status of my claim through electronic messaging at my contact number indicated on this form.
I understand that messages will be left with anyone who answers the phone or on my answering machine. Note: To avoid blocked
calls, you should program the number 1-800-325-4368 into your phone.
Complete each section before submitting your claim. Incomplete claim form submission may result in a delay in the processing of your claim.
n If your name has changed, attach a copy of your
n Benefits are payable to you unless we receive written authorization to pay them
driver’s license or other legal documentation.
elsewhere. This is called an assignment.
n Dates should be written in month/day/year format
n If this claim is for an individual covered by Medicaid, most non-disability benefits are
(i.e. 12/14/1980).
automatically assigned according to state regulations. This means we must pay the
n Social Security number is indicated by SSN.
benefits to Medicaid or to the medical provider to reduce the charges billed to Medicaid.
Section 1
Claimant statement
(completed by policy owner)
Claimant name:
SSN:
£ Male £ Female
DOB: ____ /____ /______
Relationship to policy owner: £ Self £ Spouse £ Domestic partner £ Dependent
Policy owner information
Name:
SSN:
(if other than claimant)
DOB: ____ /____ /______
Address:
City:
State:
ZIP:
Email:
Contact number:
Physician/Treating facility:
Telephone:
Address:
City:
State:
ZIP:
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. |
page 1
| ColonialLife.com | 8-15 | 70067-13
Colonial Life | HEALTH/WELLNESS SCREENING | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368
Claim Fraud Statements
For your protection, the laws of several states, including Alaska, Arkansas, Delaware, Idaho, Indiana, Louisiana, Minnesota,
New Hampshire, Ohio, Oklahoma, and others, require the following statement to appear on this claim form. Fraud Warning: Any
person who knowingly, and with intent to injure, defraud, or deceive an insurance company, files a statement of claim containing
any false, incomplete, or misleading information is guilty of insurance fraud, which is a felony.
Alabama: Any person who knowingly presents a false or fraudulent claim
Maryland: Any person who knowingly or willfully presents
for payment of a loss or benefit or who knowingly present false information
a false or fraudulent claim for payment of a loss or benefit
in an application for insurance is guilty of a crime and may be subject to
or who knowingly or willfully presents false information in
an application for insurance is guilty of a crime and may be
restitution fines or confinement in prison, or any combination thereof.
subject to fines and confinement in prison.
Arizona: For your protection Arizona law requires the following
statement to appear on this form: Any person who knowingly
New Jersey and New Mexico: Any person who knowingly
files a statement of claim containing any false or misleading
presents a false or fraudulent claim for payment of a loss is
information is subject to criminal and civil penalties.
subject to criminal and civil penalties.
New York: Any person who knowingly and with intent to
California, Rhode Island, Texas and West Virginia: For your protection,
defraud any insurance company or other person files an
California, Rhode Island, Texas and West Virginia law requires the following
application for insurance or statement of claim containing
to appear on this form: Any person who knowingly presents false or
any materially false information, or conceals for the purpose
fraudulent claim for the payment of a loss is guilty of a crime and may
of misleading, information concerning any fact material
be subject to fines and confinement in state prison.
thereto, commits a fraudulent insurance act, which is a crime,
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading
and shall also be subject to a civil penalty not to exceed five
facts or information to an insurance company for the purpose of defrauding
thousand dollars and the stated value of the claim for each
or attempting to defraud the company. Penalties may include imprisonment,
such violation.
fines, denial of insurance and civil damages. Any insurance company or
Pennsylvania: Any person who knowingly and with intent
agent of an insurance company who knowingly provides false, incomplete,
to defraud any insurance company or other person files an
or misleading facts or information to a policyholder or claimant for the
application for insurance or statement of claim containing
purpose of defrauding or attempting to defraud the policyholder or claimant
any materially false information or conceals for the purpose
with regard to a settlement or award payable from insurance proceeds shall
of misleading, information concerning any fact material
be reported to the Colorado Division of Insurance within the Department of
thereto commits a fraudulent insurance act, which is a crime
Regulatory Agencies.
and subjects such person to criminal and civil penalties
District of Columbia: It is a crime to provide false or misleading information
Puerto Rico: Any person who knowingly and with the
to an insurer for the purpose of defrauding the insurer or any other person.
Penalties include imprisonment and/or fines. In addition, an insurer may
intention of defrauding presents false information in an
deny insurance benefits if false information materially related to a claim
insurance application, or presents, helps, or causes the
was provided by the applicant.
presentation of a fraudulent claim for the payment of a loss
or any other benefit, or presents more than one claim for
Florida: Any person who knowingly and with intent to injure, defraud, or
the same damage or loss, shall incur a felony and, upon
deceive any insurer files a statement of claim or an application containing
conviction, shall be sanctioned for each violation with the
any false, incomplete, or misleading information is guilty of a felony of the
penalty of a fine of not less than five thousand (5,000)
third degree.
dollars and not more than ten thousand (10,000) dollars,
Kentucky: For your protection, Kentucky law requires the following to
or a fixed term of imprisonment for three (3) years, or both
appear on this form: Any person who knowingly and with intent to defraud
penalties. If aggravating circumstances are present, the
any insurance company or other person files a statement of claim
penalty thus established may be increased to a maximum
containing any materially false information or conceals, for the purpose
of five (5) years; if extenuating circumstances are present;
of misleading, information concerning any fact material thereto commits
it may be reduced to a minimum of two (2) years.
a fraudulent insurance act, which is a crime.
Maine, Tennessee, Virginia and Washington: It is a crime to knowingly
provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may
include imprisonment, fines or a denial of insurance benefits.
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. |
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| ColonialLife.com | 8-15 | 70067-13
Colonial Life | HEALTH/WELLNESS SCREENING | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368
Policy owner name:
Policy owner SSN:
If other than policy owner
Claimant name:
Claimant SSN:
Type of screening test performed — complete one claim form for each claimant for each calendar year
You must attach a copy of the bill(s) for each test. The bill(s) must include the facility/physician’s name and telephone number.
n
Review your policy or policies for the list of covered tests prior to completing this form.
n
Health/wellness screening benefit is NOT payable for routine physical examinations.
n
Most policies provide one health/wellness screening benefit per calendar year (refer to your policy for details).
n
n
Fill in the date of the test you had performed below.
TEST
TEST
DATE (MM/DD/YYYY)
DATE (MM/DD/YYYY)
Blood glucose
Electrocardiogram (EKG/ECG)
_____ /_____ /_____
_____ /_____ /_____
Bone marrow aspirate/biopsy
Hemoccult stool analysis
_____ /_____ /_____
_____ /_____ /_____
Breast ultrasound
Mammogram (breast)
_____ /_____ /_____
_____ /_____ /_____
CA125 (ovarian cancer)
Pap smear/thin prep pap (GYN)
_____ /_____ /_____
_____ /_____ /_____
CA 15-3 (breast cancer)
PSA (prostate)
_____ /_____ /_____
_____ /_____ /_____
Cancer vaccine
Serum protein (myeloma)
_____ /_____ /_____
_____ /_____ /_____
Carotid Doppler
Skin biopsy
_____ /_____ /_____
_____ /_____ /_____
CEA (colon cancer)
Sigmoidoscopy
_____ /_____ /_____
_____ /_____ /_____
Cholesterol (HDL /LDL /lipids)
Stress test (bicycle/treadmill)
_____ /_____ /_____
_____ /_____ /_____
Chest X-ray
Thermography
_____ /_____ /_____
_____ /_____ /_____
Colonoscopy
Triglycerides
_____ /_____ /_____
_____ /_____ /_____
Echocardiogram (Echo)
_____ /_____ /_____
Certification
Policy owner’s name:
SSN:
_________________________________________________________________________
_________________________
I have checked the answers on this claim form, and they are correct. I certify under penalty of perjury that my correct Social Security number is shown
on this form. I acknowledge that I received the Claim Fraud Statements on page two of this form and that I read the statement required by the State
Fraud Warning: Any person who knowingly and with intent to
Department of Insurance for my state, if my state was listed on the form.
defraud any insurance company or other person files a statement 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.
____________________________________________________
____________________________________________________
______________________________
Print claimant’s name
Claimant’s signature
Date
(MM/DD/YYYY)
____________________________________________________
____________________________________________________
______________________________
Print policy owner’s name
Policy owner’s signature
Date
(MM/DD/YYYY)
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. |
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| ColonialLife.com | 8-15 | 70067-13
Colonial Life | HEALTH/WELLNESS SCREENING | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368
Authorization for Colonial Life & Accident Insurance Company
For the purpose of evaluating my eligibility for insurance and eligibility for benefits under an existing policy/
certificate, including checking for and resolving any issues that may arise regarding incomplete or incorrect
information on my application or claim forms, I hereby authorize the disclosure of the following information
about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance
Company (Colonial Life) and its duly authorized representatives.
Health information may be disclosed by any health care provider or institution, health plan or health care
clearinghouse that has any records or knowledge about me, including prescription drug database or pharmacy
benefit manager, or ambulance or other medical transport service. Health information may also be disclosed
by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health
information includes my entire medical record and insurance claim history but does not include psychotherapy
notes. Non-health information, including earnings or employment history or any other facts deemed necessary
by Colonial Life to evaluate my application or claim forms, may be disclosed by any entity, person or organization
that has these records about me, including but not limited to my employer, employer representative and
compensation sources, insurance company, financial institution or governmental entities, including departments
of public safety and motor vehicle departments.
Any information Colonial Life obtains pursuant to this authorization will be used for the purpose of evaluating
and administering my claim for benefits or for evaluating my eligibility for insurance. Some information once
obtained may not be protected by certain federal regulations governing the privacy of health information, but
the information is protected by state privacy laws and other applicable laws. Colonial Life will not re-disclose
the information unless permitted or required by those laws.
This authorization is valid for two (2) years from its execution or the duration of my claim, whichever is earlier,
and a copy is as valid as the original. I know that I or my authorized representative may request a copy of this
authorization. This authorization may be revoked by me or my authorized representative at any time except to
the extent Colonial Life has relied on the authorization prior to notice of revocation or has a legal right to contest
coverage under the contract or the contract itself. If revoked, Colonial Life may not be able to evaluate my claim
or eligibility for insurance. I may revoke this authorization by sending written notice to: Colonial Life & Accident
Insurance Company, Claims Department, P.O. Box 100195, Columbia, SC 29202-3195.
I may refuse to sign this form; however, Colonial Life may not be able to evaluate and administer my claim or
eligibility for insurance.
I am the individual to whom this authorization applies or that person’s legal guardian, power of attorney
designee, conservator, beneficiary or personal representative.
_____________________________________________________________________
______________________________________________
Signature
Date signed
(MM/DD/YYYY)
XXX-XX-
_____________________________________________________________________
_______________
____________________
Printed name of individual subject to this disclosure
Last four digits of SSN
Date of birth
(MM/DD/YYYY)
If applicable, I signed on behalf of the insured as ___________________________________ (indicate relationship). If legal guardian,
power of attorney designee, conservator, beneficiary or personal representative, please attach a copy of the document granting authority.
_______________________________________________
__________________________________________
______________________
Printed name of legal representative
Signature of legal representative
Date signed
(MM/DD/YYYY)
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. |
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