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Out of Network Form

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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:

First Name*

Last Name*

Member ID#*

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

Patient Date of Birth*

Patients Relationship to Employee*

Self Dependent

Continue

Primary Member Information

Employee Information:

Employee First Name*

Employee Last Name*

Date of Birth

Employer Name*

Continue

Contact and Mailing Information

Where the reimbursement check should be mailed:

Mailing Address*

City*

State*

Zip Code*

Phone Number*

Email Address*

Continue

Request for Reimbursement

Please check all that apply.

Eye/Vision Exam

Date of Service

Amount Paid

Glasses

Lens Type

Single Vision

Bifocal

Trifocal

Progressive

Non-Prescription

Date of Service

Amount Paid for Frames or
Non-prescription eyewear

Amount Paid for Lenses

Contact Lens Fit/Evaluation

Date of Service

Amount Paid

Contact Lenses

Date of Service

Amount Paid

Upload Receipt: Upload File(s)

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

Continue

Provider or Optical Information

NAME OF PROVIDER/OPTICAL ON RECEIPT*

Phone Number of Provider/Optical*

Address of Provider/Optical*

City*

State*

Zip*

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.

Signature*

Date*

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.

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My experience with CEC’s customer service team has been one of the best experiences I've ever had in dealing with an insurance company! I can guarantee I'll be recommending Community Eye Care to everyone I know."

John
CEC Member