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 Physician’s 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 |
Created: February 03, 2026 04:47 PM
