To submit this form, first complete all required fields with accurate information. You can upload the completed form on Aflac.com or use the MyAflac mobile app. Alternatively, you can fax the form to 1-877-44-AFLAC (1-877-442-3522) or mail it to the Aflac Claims Department at 1932 Wynnton Road, Columbus, GA 31999. Ensuring all information is accurate and submitting the form promptly will help expedite claims processing and reimbursements.

Complete and submit the form for reimbursement promptly after receiving medical treatment.

The purpose of the Physician's Treatment Summary Form is to provide a detailed account of medical treatments received by a policyholder. This form is essential for documenting outpatient treatments, surgeries, and other medical procedures related to accidents, cancer, or sickness. By completing this form accurately, policyholders can facilitate the processing of insurance claims and ensure timely reimbursement of medical expenses.

• 1. Policyholder Information: Contains fields for last name, suffix, first name, date of birth, telephone number, home address, city, state, and zip code.
• 2. Patient Information: Includes fields for last name, first name, date of birth, sex, and relationship to the policyholder.
• 3. Treating Physician's Name: Fields for the physician's name, address, phone number, and fax number.
• 4. Treatment Details: Includes fields for the procedure code/description, diagnosis, facility name/address, and details of injury or sickness.
• 5. Accidental Injury Information: Fields to indicate if the treatment was due to an accidental injury and provide details such as date of injury and whether it was a motor vehicle accident.
• 6. Sickness Information: Fields to indicate if the treatment was due to a sickness and provide details such as the first consultation and treatment dates.

Failure to submit this form can result in delayed or denied insurance claims and reimbursement. It is crucial to complete and submit the form accurately and promptly.

• Delayed Claims Processing: Insurance claims may be delayed due to missing or incomplete information.
• Denial of Claims: Claims may be denied if the form is not submitted or contains inaccurate information.

• 1. Outpatient Treatment: Complete this form for any outpatient treatments received.
• 2. Surgeries: Document any surgeries performed using this form.
• 3. Accidental Injuries: Use this form to report treatments related to accidental injuries.
• 4. Cancer Diagnosis: This form is essential for documenting initial cancer diagnoses and treatments.