Colonial Life Universal Claim Form
From:_____________________________
No#of pages:_______________________
Or Mail to:
P.O. Box 100195
Columbia SC 29202-3266
Fax to: Claims 1.800.880.9325
Phone Number: 1.800.325.4368
Universal Claim Form
Please be sure to send the following Information:
Medical Documentation for your condition
Diagnosis (ICD9) codes,
Signed and dated authorization
Fax this direction.
OPTIONAL SERVICE RELEASE AGREEMENT – Please initial below for optional services. Any other marks used (check mark, x, etc.) will not be considered as authorization and will be processed as blank. I authorize Colonial Life to facilitate processing this claim by releasing its details to the individual inquiring on my behalf. Leave blank if you do not want anyone accessing your claim information.
_____sales representative
_____ plan administrator
_____spouse, family member or significant other
_____I want Colonial Life to update me on the status of my claim through electronic messaging at my home phone number indicated on this form. Messages will be left with anyone that answers the phone or on my answering machine. To avoid blocked calls, I should program the number 1.800.325.4368 into my phone. Yes, I want ALL payment(s) for this claim sent by overnight delivery. I understand payment(s) under $100.00 cannot be sent overnight and an $18.00 fee, which is subject to rate increases by carrier and does not include weekend delivery, will be deducted from my claim payment(s). We are unable to overnight mail to a P.O. Box and you must notify us in writing to discontinue this service.
*WELLNESS/HEALTH SCREENING
If you wish to file a Wellness/Cancer Screening claim for a test performed within the past 12 months, you’ll need to submit the type and date of the test performed as well as your doctor’s name and phone number. We also need to know if this is for you or another covered individual and their name and social security number. If you file by telephone or internet please retain a copy of the
medical
No#of pages:_______________________
Or Mail to:
P.O. Box 100195
Columbia SC 29202-3266
Fax to: Claims 1.800.880.9325
Phone Number: 1.800.325.4368
Universal Claim Form
Please be sure to send the following Information:
Medical Documentation for your condition
Diagnosis (ICD9) codes,
Signed and dated authorization
Fax this direction.
OPTIONAL SERVICE RELEASE AGREEMENT – Please initial below for optional services. Any other marks used (check mark, x, etc.) will not be considered as authorization and will be processed as blank. I authorize Colonial Life to facilitate processing this claim by releasing its details to the individual inquiring on my behalf. Leave blank if you do not want anyone accessing your claim information.
_____sales representative
_____ plan administrator
_____spouse, family member or significant other
_____I want Colonial Life to update me on the status of my claim through electronic messaging at my home phone number indicated on this form. Messages will be left with anyone that answers the phone or on my answering machine. To avoid blocked calls, I should program the number 1.800.325.4368 into my phone. Yes, I want ALL payment(s) for this claim sent by overnight delivery. I understand payment(s) under $100.00 cannot be sent overnight and an $18.00 fee, which is subject to rate increases by carrier and does not include weekend delivery, will be deducted from my claim payment(s). We are unable to overnight mail to a P.O. Box and you must notify us in writing to discontinue this service.
*WELLNESS/HEALTH SCREENING
If you wish to file a Wellness/Cancer Screening claim for a test performed within the past 12 months, you’ll need to submit the type and date of the test performed as well as your doctor’s name and phone number. We also need to know if this is for you or another covered individual and their name and social security number. If you file by telephone or internet please retain a copy of the
medical