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American Fidelity Assurance Company 1 800 662 1113 Fax 1 800 818 3453 Americanfidelity 2019-2026

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Register Online at americanfidelity.com Download AFmobile® from the Apple App Store or Google Play SB-32082-0219 ! Stop here! Paper claim filing is not the fastest option. Receive your money faster when you file online or through AFmobile. Claim Filing Instructions for Mail or Fax: Please complete this packet in full to avoid delays in your claim processing. For the fastest claim turnaround time, please complete and submit separate claim forms for each diagnosis. For example, if you are...

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Understanding the Gap Form

The gap form is a crucial document used primarily for insurance claims related to gaps in coverage. It serves as a formal request to reimburse expenses incurred during periods when primary insurance may not provide full coverage. This form is particularly relevant for individuals who have supplemental insurance plans, such as those offered by American Fidelity Assurance Company.

Key Elements of the Gap Form

When completing a gap form, several essential components must be included to ensure proper processing. These elements typically include:

  • Personal Information: Full name, address, and contact details.
  • Insurance Information: Policy numbers and details of the primary insurance provider.
  • Claim Details: Specifics about the services rendered and the dates they occurred.
  • Supporting Documentation: Receipts and any other relevant paperwork that validates the claim.

Steps to Complete the Gap Form

Filling out the gap form involves a systematic approach to ensure accuracy and completeness. Follow these steps:

  1. Gather all necessary documents, including your primary insurance policy and any receipts for medical services.
  2. Fill in your personal information accurately, ensuring that all details match your insurance records.
  3. Provide detailed information regarding the claim, including dates and descriptions of services.
  4. Attach all supporting documents to the form to substantiate your claim.
  5. Review the completed form for any errors before submission.

Legal Use of the Gap Form

The gap form must be completed in compliance with relevant laws and regulations to be considered valid. This includes adhering to the guidelines set forth by the Employee Retirement Income Security Act (ERISA) and ensuring that the form meets the standards of the Health Insurance Portability and Accountability Act (HIPAA) for privacy and security of health information.

Form Submission Methods

Submitting the gap form can be done through various methods, depending on the requirements of your insurance provider. Common submission methods include:

  • Online Submission: Many insurers allow for electronic submission through their websites.
  • Mail: You can send the completed form and supporting documents via postal service.
  • In-Person: Some providers may accept forms submitted directly at their offices.

Filing Deadlines and Important Dates

It is essential to be aware of filing deadlines associated with the gap form to avoid penalties or denial of claims. Typically, insurers require claims to be submitted within a specific timeframe from the date of service. Check with your insurance provider for their specific deadlines to ensure timely processing.

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Here is a list of the most common customer questions. If you can't find an answer to your question, please don't hesitate to reach out to us.

Need help? Contact support

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