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) Instructions

This form contains 139 fields organized into 46 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
ADLs Patient Cannot Perform
ADLs Patient Cannot Perform	Text	Enter the activities of daily living (ADLs) the patient is unable to perform (e.g., bathing, dressing, eating, toileting, transferring).
Attending Physician Certification Statement
Attending Physician Certification Statement	Text	Enter the attending physician’s written certification statement confirming the information provided is true and correct to the best of their knowledge and belief.
Attending Physician Printed Details and Contact
Attending Physician Name (Printed)	Text	Enter the attending physician’s full name as it should be printed on the form.
Attending Physician Degree	Text	Enter the attending physician’s professional degree or credentials (e.g., MD, DO).
Attending Physician Telephone Number	Text	Enter the attending physician’s phone number where they can be contacted.
Attending Physician Address	Text	Enter the attending physician’s mailing or office street address.
Attending Physician City	Text	Enter the city for the attending physician’s address.
Attending Physician State	Text	Enter the state for the attending physician’s address.
Attending Physician ZIP Code	Text	Enter the ZIP code for the attending physician’s address.
Attending Physician Signature, Date, and Medical ID
Attending Physician Signature	Text	Enter the attending physician’s signature to certify the accuracy of the statement.
Attending Physician Signature Date	Date	Enter the date the attending physician signed this form.
Attending Physician Medical ID Number	Text	Enter the attending physician’s medical ID number.
Authorization Signature and Date
Policy/Certificate Holder Signature	Text	Enter the policy or certificate holder's signature to authorize the electronic funds transfer transaction. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Date Signed	Date	Enter the date on which the policy or certificate holder signed this authorization. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Authorization Signature and Date Signed
Authorization Signature	Text	Enter the signature of the individual whose information is being authorized for disclosure.
Date Signed	Date	Enter the date the authorization form was signed.
Bank Account Details
9-Digit Routing Number	Text	Enter the 9-digit bank routing number for the account where payments should be deposited. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Bank Account Number	Text	Enter the bank account number for the account where payments should be deposited. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Financial Institution Name	Text	Enter the name of the bank or financial institution that holds the account. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Bank Phone Number	Text	Enter the phone number for the bank or financial institution. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Bank Account Type
Checking	Checkbox	Check this box if the bank account you want to use for direct deposit is a checking account. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Savings	Checkbox	Check this box if the bank account you want to use for direct deposit is a savings account. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Cancer/Carcinoma In Situ Diagnosis Details
Cancer/Carcinoma In Situ Date of Diagnosis	Date	Enter the date the pathological specimen(s) were obtained on which the cancer or carcinoma in situ diagnosis was made.
Diagnosed pathologically	Checkbox	Check this box if the cancer/carcinoma in situ was diagnosed pathologically (e.g., confirmed by a pathology specimen/report).
Diagnosed clinically	Checkbox	Check this box if the cancer/carcinoma in situ was diagnosed clinically (not confirmed by pathology).
Coronary Artery Bypass Surgery Details
Condition Requiring Coronary Artery Bypass Surgery	Text	Enter the medical condition that caused the patient to need coronary artery bypass surgery. Fill only if 'Underwent coronary artery bypass surgery (CABG) – Yes' is 'Yes'.
First Treatment Date for Condition	Date	Enter the date the patient was first treated for signs or symptoms of the condition that led to the coronary artery bypass surgery. Fill only if 'Underwent coronary artery bypass surgery (CABG) – Yes' is 'Yes'.
Underwent coronary artery bypass surgery (CABG) – Yes	Checkbox	Check this box if the patient underwent open heart surgery to correct narrowing or blockage of one or more coronary arteries using bypass grafts.
Underwent coronary artery bypass surgery (CABG) – No	Checkbox	Check this box if the patient did not undergo open heart surgery to correct narrowing or blockage of one or more coronary arteries using bypass grafts.
Critical Illness Condition Selection
Cancer; Carcinoma in situ; Skin Cancer	Checkbox	Check this box if the critical illness being claimed is cancer, carcinoma in situ, or skin cancer.
Heart Attack; Sudden Cardiac Arrest	Checkbox	Check this box if the critical illness being claimed is a heart attack or sudden cardiac arrest.
Coronary Artery Bypass Surgery	Checkbox	Check this box if the critical illness being claimed involved coronary artery bypass surgery.
Major Organ Transplant; Bone Marrow Transplant	Checkbox	Check this box if the critical illness being claimed involved a major organ transplant or a bone marrow transplant.
Stroke	Checkbox	Check this box if the critical illness being claimed is a stroke.
Renal Failure	Checkbox	Check this box if the critical illness being claimed is renal failure.
Heart Event	Checkbox	Check this box if the critical illness being claimed is a heart event.
Loss of Sight, Speech, Hearing, Coma, Burns, Paralysis	Checkbox	Check this box if the critical illness being claimed is loss of sight, speech, or hearing, coma, burns, or paralysis.
Direct Deposit Request Type
Start direct deposit	Checkbox	Check this box if you want to start direct deposit for your claim payment(s). Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Stop direct deposit	Checkbox	Check this box if you want to stop direct deposit for your claim payment(s). Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Change direct deposit	Checkbox	Check this box if you want to change the direct deposit information for your claim payment(s). Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Expected Return to Duties / Normal Activities Dates
Expected Return to Partial Duties Date	Date	Enter the date the physician expects the patient to be able to resume partial job duties.
Expected Return to Full Duties Date	Date	Enter the date the physician expects the patient to be able to resume full job duties.
Expected Return to Normal Activities Date (Unemployed/Retired)	Date	Enter the date the physician would expect a person of similar age, gender, and good health to resume normal and necessary activities if the patient is unemployed or retired.
First Travel Entry
First Travel Entry - Dates	Text	Enter the date or date range for the first trip (the dates the travel occurred).
First Travel Entry - To and From	Text	Enter the origin and destination locations for the first trip (from where to where you traveled).
First Travel Entry - Round Trip Mileage	Number	Enter the total round-trip miles traveled for the first trip.
Fourth Travel Entry
Fourth Travel Entry Dates	Text	Enter the date or date range for the fourth travel trip being claimed.
Fourth Travel Entry To and From	Text	Enter the starting point and destination (to and from locations) for the fourth travel trip.
Fourth Travel Entry Round Trip Mileage	Number	Enter the total round-trip miles traveled for the fourth travel trip.
General
POLICYHOLDER’S SIGNATURE	Signature
PATIENT’S SIGNATURE	Signature
Hospitalized or Skilled Nursing Facility (Yes/No, Address, Admission/Discharge)
Hospital/Facility Date Admitted	Date	Provide the date the patient was admitted to the hospital or skilled nursing facility.
Hospital/Facility Date Discharged	Date	Provide the date the patient was discharged from the hospital or skilled nursing facility.
Hospital or Skilled Nursing Facility Address	Text	Enter the full address of the hospital or skilled nursing facility where the patient was hospitalized or confined. Fill only if 'Hospitalized or in skilled nursing facility - Yes' is 'Yes'. Depends on: Hospitalized or in skilled nursing facility - Yes
Hospitalized or in skilled nursing facility - No	Checkbox	Check this box if the patient was not hospitalized and was not confined to a skilled nursing facility.
Hospitalized or in skilled nursing facility - Yes	Checkbox	Check this box if the patient was hospitalized or confined to a skilled nursing facility (and then provide the hospital address and admission/discharge dates).
Illness Onset and General Diagnosis
Illness Onset Date	Date	Enter the date when the patient’s signs and/or symptoms first appeared.
General Diagnosis (Including Complications)	Text	Enter the patient’s diagnosis, including any related complications.
Prior Medical Advice/Treatment Date	Date	Enter the date when the patient first received medical advice or treatment for this or a similar condition. Fill only if 'Has patient ever received medical advice or treatment for this or a similar condition? (Yes, When)' is 'Yes'.
Has patient ever received medical advice or treatment for this or a similar condition? (No)	Checkbox	Check this box if the patient has never received medical advice or treatment for this condition or a similar condition.
Has patient ever received medical advice or treatment for this or a similar condition? (Yes, When)	Checkbox	Check this box if the patient has received medical advice or treatment for this condition or a similar condition, and provide when it occurred.
Individual Subject to Disclosure & Relationship to Primary Certificate Holder
Individual Subject to Disclosure Name	Text	Enter the full name of the individual whose information may be disclosed (if not the primary certificate holder). Fill only if 'Primary Certificate Holder Name' is not the Individual Subject to Disclosure. Depends on: Primary Certificate Holder Name
Relationship to Primary Certificate Holder: Self	Checkbox	Check this box if the individual subject to disclosure is the primary certificate holder (self). Fill only if 'Primary Certificate Holder Name' is not the Individual Subject to Disclosure (fill one relationship option if applicable). Depends on: Primary Certificate Holder Name
Relationship to Primary Certificate Holder: Spouse	Checkbox	Check this box if the individual subject to disclosure is the primary certificate holder’s spouse. Fill only if 'Primary Certificate Holder Name' is not the Individual Subject to Disclosure (fill one relationship option if applicable). Depends on: Primary Certificate Holder Name
Relationship to Primary Certificate Holder: Domestic Partner	Checkbox	Check this box if the individual subject to disclosure is the primary certificate holder’s domestic partner. Fill only if 'Primary Certificate Holder Name' is not the Individual Subject to Disclosure (fill one relationship option if applicable). Depends on: Primary Certificate Holder Name
Relationship to Primary Certificate Holder: Child	Checkbox	Check this box if the individual subject to disclosure is the primary certificate holder’s child. Fill only if 'Primary Certificate Holder Name' is not the Individual Subject to Disclosure (fill one relationship option if applicable). Depends on: Primary Certificate Holder Name
Relationship to Primary Certificate Holder: Stepchild	Checkbox	Check this box if the individual subject to disclosure is the primary certificate holder’s stepchild. Fill only if 'Primary Certificate Holder Name' is not the Individual Subject to Disclosure (fill one relationship option if applicable). Depends on: Primary Certificate Holder Name
Relationship to Primary Certificate Holder: Grandchild	Checkbox	Check this box if the individual subject to disclosure is the primary certificate holder’s grandchild. Fill only if 'Primary Certificate Holder Name' is not the Individual Subject to Disclosure (fill one relationship option if applicable). Depends on: Primary Certificate Holder Name
Major Organ Transplant Details
Date First Treated for Major Organ Transplant Condition	Date	Enter the date the patient was first treated for signs or symptoms related to the condition requiring the major organ transplant. Fill only if 'Yes (Major Organ Transplant Surgery)' is 'Yes'.
Yes (Major Organ Transplant Surgery)	Checkbox	Check this box if the patient underwent surgery to receive a human heart, liver, lung, kidney, pancreas, or bone marrow.
No (Major Organ Transplant Surgery)	Checkbox	Check this box if the patient did not undergo surgery to receive a human heart, liver, lung, kidney, pancreas, or bone marrow.
Myocardial Infarction Criteria - First Row (EKG Findings)
First Row (EKG Findings) - Yes	Checkbox	Check this box if new and serial electrocardiographic (EKG) findings are consistent with myocardial infarction.
First Row (EKG Findings) - No	Checkbox	Check this box if new and serial electrocardiographic (EKG) findings are not consistent with myocardial infarction.
Myocardial Infarction Criteria - Fourth Row (Chest Pain Consistent With MI)
Fourth Row - Chest pain consistent with myocardial infarction: Yes	Checkbox	Check this box if the patient had chest pain consistent with myocardial infarction (heart attack).
Fourth Row - Chest pain consistent with myocardial infarction: No	Checkbox	Check this box if the patient did not have chest pain consistent with myocardial infarction (heart attack).
Myocardial Infarction Criteria - Second Row (Cardiac Enzymes Elevated)
Second Row - Cardiac Enzymes Elevated - Yes	Checkbox	Check this box if cardiac enzymes were elevated above generally accepted normal laboratory levels for creatine phosphokinase (CPK) (with a CPK-MB measurement used) for this myocardial infarction.
Second Row - Cardiac Enzymes Elevated - No	Checkbox	Check this box if cardiac enzymes were not elevated above generally accepted normal laboratory levels for creatine phosphokinase (CPK) (with a CPK-MB measurement used) for this myocardial infarction.
Myocardial Infarction Criteria - Third Row (Diagnostic Studies Confirmed MI)
Third Row - Yes (Diagnostic studies confirmed MI)	Checkbox	Check this box if diagnostic studies confirmed a myocardial infarction and the occlusion of one or more coronary arteries.
Third Row - No (Diagnostic studies confirmed MI)	Checkbox	Check this box if diagnostic studies did not confirm a myocardial infarction and the occlusion of one or more coronary arteries.
Myocardial Infarction Date of Diagnosis
Myocardial Infarction Date of Diagnosis	Date	Enter the date the patient met all criteria for myocardial infarction (heart attack) diagnosis. Fill only if 'First Row (EKG Findings) - Yes', 'Second Row - Cardiac Enzymes Elevated - Yes', 'Third Row - Yes (Diagnostic studies confirmed MI)', 'Fourth Row - Chest pain consistent with myocardial infarction: Yes' are all 'Yes'.
Other Treating Physician (Yes/No and Details)
Other Treating Physician Details	Text	Enter the names and addresses of any other physicians who treated the patient for this condition. Fill only if 'Other Treating Physician - Yes' is 'Yes'. Depends on: Other Treating Physician - Yes
Other Treating Physician - No	Checkbox	Check this box if the patient was not treated by any other physician(s) for this condition.
Other Treating Physician - Yes	Checkbox	Check this box if the patient was treated by other physician(s) for this condition and you will provide their names and addresses.
Patient Identification
Patient Name	Text	Enter the full name of the patient.
Date of Birth	Date	Enter the patient's date of birth.
Patient Information
Patient's Name	Text	Enter the patient's full legal name.
Date of Birth	Date	Enter the patient's date of birth.
Patient Information (Name/Relationship/DOB/Gender)
Patient Name	Text	Enter the patient's full name.
Relationship to Policyholder	Text	Enter the patient's relationship to the policyholder (e.g., self, spouse, child).
Patient Date of Birth	Date	Enter the patient's date of birth.
Patient Gender	Text	Enter the patient's gender.
Patient Mobility/Confinement Status
Ambulatory	Checkbox	Check this box if the patient is ambulatory (able to walk/move about).
Bed Confined	Checkbox	Check this box if the patient is confined to bed.
House Confined	Checkbox	Check this box if the patient is confined to the home (not able to leave the house).
Patient Signature Date
Patient Signature Date	Date	Enter the date on which the patient signed the form.
Policy/Certificate Holder Information
Policy/Certificate Holder Name (Print)	Text	Enter the full name of the policy/certificate holder as it should appear on the form. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Policy/Certificate Holder Address	Text	Enter the street address of the policy/certificate holder. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Policy/Certificate Holder City/State/ZIP	Text	Enter the city, state, and ZIP code for the policy/certificate holder’s address. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Policy/Certificate Holder Phone Number	Text	Enter the policy/certificate holder’s phone number. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Policy/Certificate Holder Email Address	Text	Enter the policy/certificate holder’s email address. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Employer Name or Group Number	Text	Enter the employer name or the group number associated with the policy/certificate holder. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Certificate Number	Text	Enter the certificate number associated with the policy. Fill only if 'Policy/Certificate No.' does not contain both letters and numbers. Depends on: Policy/Certificate Number
Policyholder Basic Information
Employer Name	Text	Enter the name of the policyholder’s employer.
Policy/Certificate Number	Text	Enter the policy or certificate number associated with the coverage.
Social Security Number	Text	Enter the policyholder’s Social Security number.
Date of Birth	Date	Enter the policyholder’s date of birth.
Gender	Text	Enter the policyholder’s gender.
Policyholder Insurance & Contact (Provider/ID/Email)
Policyholder Major Medical Insurance Provider	Text	Enter the name of the policyholder’s primary major medical insurance provider.
Policyholder Major Medical ID Number	Text	Enter the policyholder’s major medical insurance ID number.
Policyholder Email Address	Text	Enter the policyholder’s email address.
Policyholder Name, Address, Phone
Policyholder Telephone Number	Text	Enter the policyholder’s telephone number.
Policyholder Address (City, State, ZIP)	Text	Enter the policyholder’s complete mailing address including street address, city, state, and ZIP code.
Policyholder Name	Text	Enter the full legal name of the policyholder.
Policyholder Signature Date
Policyholder Signature Date	Date	Enter the date on which the policyholder signed the form.
Primary Certificate Holder Information
Primary Certificate Holder Name	Text	Enter the full name of the primary certificate holder.
Primary Certificate Holder SSN (Optional)	Text	Enter the primary certificate holder’s Social Security Number, if available.
Certificate Number(s)	Text	Enter the certificate number or multiple certificate numbers associated with the coverage.
ZIP Code	Text	Enter the ZIP code for the primary certificate holder’s mailing address.
Renal Failure Details
Cause of Renal Disease	Text	Enter the cause of the patient’s renal disease. Fill only if 'End Stage Renal Failure - Yes' is 'Yes'.
Date of Diagnosis	Date	Provide the date a doctor or physician determined that the patient should begin renal dialysis. Fill only if 'Regular dialysis or kidney transplant required - Yes' is 'Yes'.
Date First Treated	Date	Provide the date the patient was first treated for signs or symptoms of this condition. Fill only if 'End Stage Renal Failure - Yes' is 'Yes'.
Renal Failure Qualification - End Stage Renal Failure
End Stage Renal Failure - Yes	Checkbox	Check this box if the patient has end stage renal failure (chronic, irreversible failure to function of both kidneys).
End Stage Renal Failure - No	Checkbox	Check this box if the patient does not have end stage renal failure (chronic, irreversible failure to function of both kidneys).
Renal Failure Qualification - Regular Dialysis or Transplant
Regular dialysis or kidney transplant required - Yes	Checkbox	Check this box if the patient’s kidney failure necessitates regular renal dialysis (hemo-dialysis or peritoneal dialysis at least weekly) or has resulted in a kidney transplantation.
Regular dialysis or kidney transplant required - No	Checkbox	Check this box if the patient’s kidney failure does not necessitate regular renal dialysis (at least weekly) and has not resulted in a kidney transplantation.
Restrictions and Limitations
Restrictions and Limitations	Text	Describe the patient’s specific restrictions and limitations, quantifying them where possible (e.g., hours, weight limits, activity restrictions).
Second Travel Entry
Second Travel Entry Dates	Date	Enter the date(s) for the second round trip travel associated with this claim.
Second Travel Entry To and From	Text	Enter the origin and destination locations for the second round trip travel (to and from).
Second Travel Entry Round Trip Mileage	Number	Enter the total round-trip miles traveled for the second trip.
Specific Job Duties Patient Cannot Perform
Specific Job Duties Patient Cannot Perform	Text	List the specific job duties the patient is unable to perform due to their condition.
Stroke Details
Stroke Date of Diagnosis	Date	Enter the date the patient’s stroke occurred based on documented neurological deficits and neuroimaging studies. Fill only if 'Stroke - Yes' is 'Yes'.
Stroke - Yes	Checkbox	Check this box if the patient had a stroke (apoplexy) secondary to rupture or acute occlusion of a cerebral artery.
Stroke - No	Checkbox	Check this box if the patient did not have a stroke as defined in this section.
Third Travel Entry
Third Travel Entry - Dates	Text	Enter the date or date range for the third trip.
Third Travel Entry - To and From	Text	Enter the origin and destination locations for the third trip.
Third Travel Entry - Round Trip Mileage	Number	Enter the total round-trip mileage for the third trip.
Unable to Perform Job Duties (Yes/No and Dates)
Unable to Perform Job Duties - Dates	Text	Enter the date(s) or date range during which the patient was unable to perform job duties (if the answer is Yes). Fill only if 'Unable to perform job duties - Yes' is 'Yes'. Depends on: Unable to perform job duties - Yes
Unable to perform job duties - No	Checkbox	Check this box if the patient is not unable to perform their job duties.
Unable to perform job duties - Yes	Checkbox	Check this box if the patient is unable to perform their job duties (and then provide the applicable dates).