Out-of-Network
Claim Form

How to File an Out-of-Network Claim:
  • Complete all applicable fields on this form. Missing information may delay processing and reimbursement.
  • Submit one claim form for each patient to CEC within 180 days of the date of service.
  • Please upload a copy of your itemized receipt(s) for each service or product included on this claim form.
  • This form must be electronically signed by the patient or his/her authorized representative.

 

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Patient Information

Details of the person who received the service:

If you do not know the Member ID number, please contact CEC at 888-254-4290.

Patients Relationship to Employee*

Primary Member Information

Employee Information:

Contact and Mailing Information

Where the reimbursement check should be mailed:

Request for Reimbursement

Please check all that apply.

    Accepted file types: .jpg, .png, and .pdf Max file size 8MB

    Provider or Optical Information

    Patient’s or Authorized Person’s Signature: By typing below, I authorize the release of any medical or other information necessary to process this claim.

    IMPORTANT: Reimbursements are processed within a few weeks from the date we receive your electronic out-of-network claim form. For questions about your Member ID number or eligibility, please contact CEC at 888-254-4290.

    CEC’s Customer Service reps are courteous and helpful.  They go above and beyond in assisting me with my questions."

    Carol P.
    Member Since 2007