Colonial Life - Health / Wellness Screening Claim Form
ADVERTISEMENT
1
2
3
4Health/Wellness Screening
Fax to: Claims 1.800.880.9325
From:_________________________
Claim Form
No# of pages:_________________
Or!Mail!to:!P.O.!Box!100195!!!!!!!!!!!!!!!!!
Columbia!SC!29202%3195!
Fax this direction.
If#your#name#has#changed,#please#attach#a#copy#of#legal#documentation#(i.e.#marriage#certificate#or#driver’s#license)
Birth Date
Social Security Number for Claimant
(First, Last)
Health/Wellness Screening performed on
_____/_____/_____
☐
Male
☐ Female
Relationship to Policy Owner:
___ self ___ spouse ___ dependent ____domestic partner
Policy owner (First, Last)
Birth Date
Social Security Number
_____/_____/_____
Mailing Address (Street or PO Box)
(Apartment/Unit/Lot Number)
(City)
(State)
(Zip)
Daytime Phone
Policy owner e-mail address
Physician/ Treating Facilities Name
Phone
Type of Test Performed – Please complete one claim form for each claimant and for each calendar year.
• Please review your policy(ies) for the list of covered tests prior to completing this form.
• The Health/Wellness Screening benefit is not payable for routine physical examinations.
• Most policies provide one Health/Wellness benefit per calendar year; please refer to your policy for detail.
• Proof of loss is required. Please fill in the date for the test you had performed.
Attach a detailed billing statement or medical records which confirm the date and type of test(s) performed
as well as the facility/doctor’s name and telephone number.
Blood Glucose
_____/_____/_____
Electrocardiogram (EKG/ECG)
_____/_____/_____
Bone Marrow Testing
_____/_____/_____
Hemocult 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)
_____/_____/_____
70067%12
!!!!!!!!!!!!!!!!!!!!!!
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
!
1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business