Patients with Colonial Life hospital indemnity or outpatient surgery coverage file this 8-page claim after a hospital, ICU or rehabilitation stay, an outpatient surgery or a diagnostic procedure. Colonial Life pays from itemized bills and the operative report, and when the patient can't provide billing statements it asks the doctor to complete and sign the physician sections instead. Those sections confirm dates, diagnosis codes and procedure codes.
The policy owner completes Section 1 (claimant statement), Section 2 (accidental injury), the certification and Section 3 (confinement dates plus child care, pet boarding and travel questions). The physician completes Section 4 for hospital or rehabilitation confinement and Section 5 for surgery or a diagnostic procedure; Section 6 lists behavioral health therapy visits.
The policy owner gives the claimant's name, sex, date of birth, SSN and relationship to the policy owner (self, spouse, domestic partner or dependent), then the policy owner's own details if different. This section also lists the primary physician and the referring physician or hospital, with their phone, fax and address. An optional release lets Colonial Life discuss the claim with an agent, the employer or a family member.
For an accident, the policy owner gives the date the accident occurred (not when it was treated), on-job or off-job, prior treatment for the same condition, any hospital admission dates and times, and how the accident happened, with the accident report attached for an auto accident. The section also asks which type of claim is being filed: diagnostic procedure, emergency room, hospital confinement or ICU, rehabilitation or surgical procedure.
The claimant and policy owner print their names, sign and date, certify the SSN under penalty of perjury and acknowledge the state fraud statements. Section 3 records the dates of hospital confinement and the date of surgery, then asks about paid child care, overnight pet boarding, companion lodging when the facility was more than 50 miles away, and travel of more than 50 miles for the surgery or stay. Receipts go with the yes answers.
Enter the diagnosis and ICD codes, any diagnostic procedure date and code, the hospital, and the admitting and treating physicians. Give the date first treated for the condition, then admission and release dates and times for hospital confinement or observation, ICU confinement and rehabilitation unit confinement, each separately. List every date in the 18 months before this condition that the patient received advice, diagnosis or treatment for it or a related condition.
For a pregnancy confinement, add the date first treated for the pregnancy, delivery date, type of delivery, surgical procedure code, the newborn's confinement dates and diagnosis, and whether anesthesia was given. The physician signs and dates, then gives name, patient account number, address, tax ID or SSN and contact numbers, and answers whether the office accepts the standard HIPAA release and records requests by fax, and whether an authorization is on file.
Give the date first treated, whether the surgery was inpatient or outpatient, at a hospital or ambulatory surgery center, the facility name, and admission and release dates and times. Enter the procedure description and codes, whether anesthesia was given and whether by a licensed anesthesiologist, whether the condition is due to an accidental injury, up to four post-surgery office visit dates, diagnosis and ICD codes, diagnostic procedures with dates and CPT codes, and the 18-month treatment history.
Lists behavioral health therapy given for the claim, with up to three entries of the treating physician's name, phone number and date of treatment. The form states that the therapy must be due to a covered loss. A fraud warning beneath the section notes that it applies to the attending physician portions of the claim form.
The last two pages are for the insured. The optional direct deposit form sets up, changes or cancels electronic payment of approved benefits into one US account. The HIPAA authorization lets providers, insurers, pharmacies and others release records to Colonial Life; it is valid for two years or the duration of the claim, whichever is earlier, and a copy is as valid as the original.
Download the current version from the source each time; forms change without notice.
Hospital Confinement/Outpatient Surgery Claim
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Section 4, hospital confinement or rehabilitation confinement, and Section 5, surgery or diagnostic procedure, both marked as completed by the physician, each with its own signature block. Section 6 lists behavioral health therapy by physician name and treatment date. The policy owner completes Sections 1 to 3 and signs the certification.
Colonial Life asks for the itemized hospital bill showing admission and discharge dates and daily room charges, and for surgery the itemized surgeon's bill with procedure codes and the operative report. The form says that if the patient is unable to provide billing statements, the doctor should complete and sign the claim form.
When the confinement is for pregnancy or its complications, Section 4 asks for the date first treated for the pregnancy, the delivery date, vaginal or C-section delivery, the surgical procedure code, the newborn's hospital confinement dates and diagnosis, and whether anesthesia was used. The physician then signs Section 4.
Yes. The patient can log in at coloniallife.com, choose File an Online Claim and upload the completed physician sections and bills, and can set up direct deposit at the same time. Colonial Life says online filing gets benefits paid in less time than a paper claim sent by fax or mail.