Join CEAB as physician form

Form

Join CEAB as physician form

CEAB

CEAB welcomes physician participation in our expanding nationwide network of Independent Medical Evaluation specialists. We are committed to excellence and provide robust administrative support to ensure a smooth, efficient IME process from scheduling through report completion. If you would like additional information, please submit the form below or email your contact details to info@ceabime.com One of our associates will follow up to provide further details about our services and partnership

If you would like more information, please complete the form below or email us your info at: info@ceabime.com. One of our associates will provide you with more details on our company and services.

Specialty(Required)

Are you a board-certified physician?(Required)

YES

State(s) where you hold a license to practice:(Required)

Have you performed independent medical evaluations before? *(Required)

YES

If yes, for what carrier(s) / company(ies)?

In what city or geographic area(s) do you perform exams?

Physician Identity & Contact Information

First Name(Required)

Last Name(Required)

Street(Required)

Physician’s Practice Name(Required)

City(Required)

Email(Required)

State / Province / Region

Phone

ZIP / Postal Code(Required)

Fax

Country(Required)

Important Note:

We will not release your information to any outside organization. You may also email your information to us directly at info@ceabime.com. We will not provide your name, address, email address, or any personal information to any third party.

Legal / Privacy Consent

I understand that this form is for initial contact and quote requests only, and that no diagnosis, treatment, or medical advice will be provided through this website.

Full disclaimer:

Important – Please read before submitting: CEAB Investments LP (“CEAB”) coordinates administrative and logistical support for cross-border telehealth and second-opinion services. This online form is intended only for initial contact and to request information or a quote.

Do not include detailed medical history, test results, diagnostic images, claim numbers, or any highly sensitive health information in this form. After submission, CEAB may contact you to obtain additional information through more secure channels, where appropriate.

Completion of this form does not create a doctor–patient relationship, a treatment relationship, or a legal representation relationship with CEAB or any affiliated physician, clinic, or organization. Any clinical care, medical advice, diagnosis, or treatment will be provided only by licensed healthcare professionals through their own platforms and regulatory frameworks, not through this website.

By clicking “Submit,” you confirm that you are providing information voluntarily, that you are at least 18 years old or authorized to act on behalf of the patient, and that you agree that CEAB may contact you using the contact details provided to discuss your request. You also acknowledge that CEAB will not share, disclose, or release your personal information (including your name, address, telephone number, or email address) to any outside organization without your explicit permission.

I have read and agree to the notice above and confirm that I will not include detailed medical or
highly sensitive information in this form.