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Aflac Physician Treatment Summary Form
Provider).
*Policy Number:
Policyholder Information: This * denotes a required field.
*Last Name
Suffix
*Date of Birth (mm/dd/yy)
/
*First Name
MI
Telephone Number where we can reach you
/
-
-
*Home Address
*City
*State
*Zip Code
-
Patient Information:
*Last Name
*First Name
*Date of Birth (mm/dd/yy)
/
*Sex:
Male
Female
*Relationship:
Treating Physician's Name
Date
Primary Policyholder
Address
Procedure Code/Description
Was this treatment due to an accidental...
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