CEBT: A Higher Standard of Quality

Benefit by Trust

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Forms

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Select a form from the list below.

This symbol denotes a Downloadable Form. You can print it and fill it out.

This symbol denotes an Online Form. You can fill it out right in the site.

Employee / Member

CEBT HIPAA Documents

CEBT HIPAA Release Form

Caremark (prescription drug coverage provider)

Prescription Drug Mail Order Form

Prescription Drug Standard Claim Form

UMR

UMR Other Insurance Form

UMR Other Insurance Form

UMR Medical/Vision Claim Form

UMR Possible Third Party Liability Form

Kaiser

Kaiser Student Certification Form

Kaiser Member Claim Reimbursement Form

Delta Dental

Dental Claim Form

VSP

Vision Care Out of Network Reimbursement Form
*You could also submit your claim online at vsp.com

Standard Insurance Company

Life Conversion Request Form

Life Portability Application

Voluntary Life Medical History Statement

CEBT Life Claim Packet

Life Waiver of Premium due to Disability Form

Life and AD&D Claim Form

SDA LTD Claim Packet

SDA STD Claim Packet

Employer / Payroll / Human Resource

CEBT

CEBT Enrollment / Change Card

Evidence of Group Health Coverage

CEBT Notice of Termination

General

Affidavit of Common Law Marriage

CEBT General Notice of COBRA Continuation Coverage Rights

Group Supply Request Form

Group Supply Request Form


Travel Assistance Program

Travel Assistance Employee Brochure

Employee Flyer

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555 17th Street, Suite 2050 | Denver, CO 80202

  • Phone: (303) 773-1373
  • Phone: (800) 332-1168
  • Fax: (303) 773-1685

Office Hours

  • Mon-Thur 7:30am to 4:30pm MST
  • Fridays 7:30am to 4:00pm MST

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