Continental American Insurance Company (CAIC) / Aflac Group Critical Illness Claim Form (with Attending Physician’s Statement, HIPAA Authorization to Obtain Information, and Electronic Funds Transaction Authorization) Completed Form Examples and Samples
View filled-out examples and samples of the Continental American Insurance Company (CAIC) / Aflac Group Critical Illness Claim Form. Our detailed guides demonstrate how to correctly complete the Attending Physician’s Statement, HIPAA Authorization, and Electronic Funds Transaction Authorization to ensure a smooth claims process.
CAIC / Aflac Group Critical Illness Claim Form Example - Heart Attack
How this form was filled:
This example demonstrates how to fill out a CAIC / Aflac Group Critical Illness Claim Form following a heart attack diagnosis. It includes correctly populated employee and patient information, a comprehensive Attending Physician's Statement, a signed HIPAA Authorization, and a completed Electronic Funds Transaction (EFT) Authorization for direct deposit of the benefit.
Information used to fill out the document:
- Employee Name: Jane A. Miller
- Date of Birth: 06/15/1978
- Policy Number: GCI-987654321
- Employer Name: Global Tech Solutions Inc.
- Address: 456 Oak Avenue, Anytown, ST 12345
- Critical Illness Diagnosed: Heart Attack (Myocardial Infarction)
- Date of Diagnosis: 02/10/2026
- Attending Physician: Dr. Robert Chen, MD, FACC
- Physician's Practice: Anytown General Hospital
- Diagnosis Code (ICD-10): I21.3
- HIPAA Authorization Signed Date: 02/28/2026
- EFT Authorization Status: Completed for Checking Account
- Bank Name: First National Bank of Anytown
What this filled form sample shows:
- Accurately completed Employee and Patient Information sections for proper identification and policy lookup.
- A thorough Attending Physicianâs Statement section, detailing the specific critical illness diagnosis, date of first symptoms, and physician's credentials.
- A properly signed and dated HIPAA Authorization to Obtain Information, which is crucial for allowing CAIC / Aflac to process the claim by verifying medical records.
- A filled-out Electronic Funds Transaction (EFT) Authorization to enable fast and secure direct deposit of the insurance benefit into the claimant's bank account.
Form specifications and details:
| Use Case: | Critical Illness Claim for a Heart Attack (Myocardial Infarction) |
| Form Name: | Continental American Insurance Company (CAIC) / Aflac Group Critical Illness Claim Form |
| Attached Documents: | Attending Physician’s Statement, HIPAA Authorization to Obtain Information, Electronic Funds Transaction Authorization |
| Categories: | insurance forms, Aflac forms, insurance claim forms, critical illness forms, CAIC forms, VA claim forms, authorization forms, PA state forms, physician forms, insurance authorization forms, company forms, HIPAA forms, group insurance forms, NJ state forms |
| Created: | February 03, 2026 04:47 PM |