Employees with Aflac Group supplemental short-term disability coverage, issued by Continental American Insurance Company, use this form for the initial claim when an accident, sickness or pregnancy keeps them from working. The attending physician completes Part C, certifying the diagnosis, objective findings, treatment and expected return to work. The employee and employer complete Parts A and B, and the packet goes to Aflac Group by email, fax or mail.
The physician certifying the disability completes Part C on or after the disability date. The employee completes Part A and signs the HIPAA authorization, and the employer's benefits or HR department completes Part B unless the employee is self-employed.
The employee completes this on or after the disability date: policy number, Social Security or ID number, major medical carrier, contact details, employer and occupation. They report whether the condition is work related and whether a workers' compensation claim was filed and its status, the date symptoms first appeared, the treating, referring and primary doctors, hospital dates, a description of the illness or injury, dates not worked at all or worked less than full time, and the return-to-work date.
The HIPAA authorization within Part A lets Continental American Insurance Company obtain the employee's entire medical record, excluding psychotherapy notes, from any provider, health plan or the MIB, plus financial and employment records. It is valid for two years or the duration of the claim, whichever is later, and a copy is as valid as the original. The employee or a legal representative signs it, and Aflac's claim page also asks for its separate HIPAA form.
The employer's benefits or human resources department completes this unless the employee is self-employed, in which case a 1099 form is submitted. It records the job title, physical demands such as lifting, stooping and standing, the work schedule, the last day at work, dates not worked and part-time dates, light duty availability, other income such as salary continuance or sick pay, whether the employer pays any premium or it is pre-tax under Section 125, and basic monthly earnings.
The physician certifying disability completes this on or after the disability date. Enter the date the patient became disabled, when symptoms first appeared or the accident occurred, whether it is a workers' compensation injury and whether the patient had the same or a similar condition before. Give the diagnosis with complications and ICD codes, subjective symptoms, objective findings including current x-rays, EKGs and laboratory data, and the names of other physicians treating the current diagnosis.
For a pregnancy-related disability, enter the last menstrual period, the estimated date of confinement, the date of delivery and the method of delivery, vaginal or cesarean, and list any pregnancy complications. These fields sit within Part C, so the treatment dates, confinement status and return-to-work questions that follow still need answers.
Give the first and last dates treated for this condition and the nature of treatment, including surgery and medications prescribed. If surgery took place, give the date and type, and send the surgical report the instructions list as supporting documentation. Mark whether the patient has recovered, improved, retrogressed or is unchanged, and whether the patient is ambulatory, house confined, bed confined or hospital confined, with hospital dates and the hospital's name and address.
Circle when you expect a fundamental change in the patient's condition, from one month to never, and give the date of return to full duty without restrictions and when trial employment could begin with restrictions, as full-time, part-time or light duty. Then classify the physical impairment using the Dictionary of Occupational Titles scale, from Class 1, no limitation and capable of heavy work, through Class 5, severe limitation and incapable of minimum sedentary activity.
List the specific activities and work duties the patient is incapable of performing, and add remarks about the patient's condition. Enter the attending physician's name, fax and telephone numbers, medical ID number and address, then sign and date. The signature certifies that the information is based on reasonable medical probability and is true and correct to the best of the physician's knowledge and belief.
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Aflac Group Disability Claim Form
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Part C says it is to be completed by the physician certifying disability on or after the disability date to avoid processing delays. Part A carries the same instruction for the employee. A statement dated before the patient actually became disabled can therefore slow the claim down.
This form covers the initial filing only. The instructions say that if the disability is being extended, the employee needs to complete the Supplemental Claim form; Aflac Group posts it as the Continuing Disability Claim Form on the same claims page, next to the initial Disability Claim Form.
Yes. Part C has pregnancy fields for the last menstrual period, the estimated date of confinement, the date of delivery, the method of delivery (vaginal or cesarean) and any pregnancy complications. The rest of Part C, including treatment dates, confinement status, impairment class and return-to-work dates, applies as well.
Part B is completed by the employer's benefits or human resources department unless the employee is self-employed, in which case a 1099 form is submitted for verification. It records job duties, work schedule, dates not worked, light duty availability, other income and whether a workers' compensation claim was filed.