Aflac Group's term-to-120 life policies can pay long term care, home health care and adult care benefits, and this four-page claim requests them. The attending physician completes Section B, recording the diagnosis and ICD code, the activities of daily living the patient needs help with, cognitive impairment, and the care providers and settings involved.
The insured completes Section A in full, including ADLs and the qualified care provider, and signs the disclosure authorization. The attending physician completes and signs Section B.
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Long Term Care – Term to 120 Claim Form (Aflac Group)
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Section B asks for the date of first symptom and first consultation, any prior similar illness, the referring source, chronic disease or defects, diagnosis and ICD code, which ADLs need assistance, cognitive impairment, the certifying physician, other doctors consulted, and the agencies or facilities providing care.
Both the insured's section and the physician's section list bathing, continence, dressing, walking, eating and transferring. The physician checks each activity the patient needs assistance with and separately indicates whether the patient has a cognitive impairment.