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Short-Term Disability Claims

To file a short-term disability claim, please complete the appropriate claim form and follow the guidelines below:
 
First Claim for Short-Term Disability (Form S-00198)

  • Include an authorization signed and dated by the patient with every claim.
  • Have the patient complete and sign Section A: Patient Information.
  • Have the employer complete and sign Section B: Employer's Information. Also, have the employer complete the pre-tax or after-tax question.
  • If you are self-employed, send a copy of your current business license and most recent quarterly tax records.
  • Have the physician complete and sign Section C: Physician's Information.
  • The claim form must include:
    • Where and when the accident took place (for accident claims)
    • Diagnosis and treatment dates (for sickness claims)
    • Dates of disability
    • Name and phone number of the physician

Additional information may be required.

Second and Subsequent Claims for Short-Term Disability (Form S-13270.1)

  • Have the patient complete and sign Section A: Patient Information.
  • Have the physician complete and sign Section B: Physician's Information.
  • Have the employer complete and sign Section C: Employer's Information.

Short-Term Disability Insurance Claims | Aflac New York Insurance