Aflac Ub04 Form. *last name suffix *first name mi *date of birth (mm/dd/yy) Web what you need to file a claim patient’s name and date of birth.patient’s relationship to policyholder.
6 Ub 04 form Template FabTemplatez
Web hospital indemnity claim form instructions. Supporting documentation needed itemized bill if there was a hospital stay (ub04 from the hospital or medical facility) Web the ub04 claim form is used by facilities rather than physicians for their health insurance billing. Have the treating physician complete section b:. Web ub 04 form aflac. Hospitals, rehabilitation centers, ambulatory surgery centers, clinics, etc need to bill their services on the ub04 form in order to get paid. Definitions & acronyms emergency room (er). Physician billing is done on the cms 1500 claim forms. Web life claim forms for the state of illinois must be obtained by contacting aflac worldwide headquarters at 800.992.3522 to have the appropriate forms sent to you. Date of injury or when symptoms first occurred.physician’s name, address and phone/fax number.
To avoid delays in processing of your claim form, complete each section attaching documentation below whenit applies. This * denotes a required field. Web hospital indemnity claim form instructions. Aflac accident injury claim form accidental injury claim form failure to complete this form in its entirety may result in a delay in processing this claim. Policyholder information (please print.) first name initial last name mailing address city statezip check box if this is anew permanent address: Web ub 04 form aflac. Our customer service representatives are here to assist you monday. We are providing two different versions in case one works better for you than the other. Definitions & acronyms emergency room (er). Hospitals, rehabilitation centers, ambulatory surgery centers, clinics, etc need to bill their services on the ub04 form in order to get paid. Web the ub04 claim form is used by facilities rather than physicians for their health insurance billing.
