Vsp Reimbursement Form PDF Details

Navigating the world of insurance claims can often feel like a maze, especially when it comes to health benefits like vision care. This is where the VSP Member Reimbursement Form comes into play, a crucial document for those seeking reimbursement for out-of-pocket vision care expenses not directly covered by their provider. When utilizing this form, it's important to fill it out meticulously, using blue or black ink, and to include all necessary itemized receipts for your expenses. The form requires members to provide comprehensive information, including policyholder details, patient information — specifying the relationship to the member, and a detailed breakdown of costs related to vision care services and products. Additionally, the form accommodates claims involving other insurers, asking members to disclose if another insurance company has already processed a payment. It is crucial to acknowledge that the form carries severe warnings against false claims, with different states listing specific consequences for fraudulent submissions. Completing this form accurately ensures a smoother reimbursement process from VSP, a significant player in the vision insurance sector, helping members manage their vision care costs more efficiently.

QuestionAnswer
Form NameVsp Reimbursement Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesvsp claim form printable, vsp member, out of network reimbursement form vsp, vsp claim forms

Form Preview Example

VSP Member Reimbursement Form

To request reimbursement, complete this form (in blue or black ink), enclose a legible copy of your itemized receipt(s), and send them to the following address. Be sure to keep a copy for your records.

VSP

 

 

 

 

 

 

 

 

 

 

PO Box 385018

 

 

 

 

 

 

 

 

 

 

Birmingham, AL 35238-5018

Ref #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

Policyholder/Employee ID or Last 4 Digits of SSN

 

 

 

 

 

 

Date of Birth

/

 

 

 

 

 

 

 

First Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Employer/

 

 

 

 

 

 

 

(

 

 

 

 

 

 

 

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Daytime Phone #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

 

Member Spouse Child

If the patient is a child over the age of 18:

Domestic Partner

/

Date of Birth

/

Is the child a full-time student? Yes

No

Is the child disabled? Yes

No

Claim Information (Dollar amounts must match the attached receipts)

Exam $

Frame $

Lens $

Lens tints $ or coatings

Contacts $

Total Paid $

(Do not add tax or shipping)

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Lens Type: (Choose One)

Single Progressive

Bi-focal

 

Lenticular

Tri-focal

 

Contacts

 

Date services were received

/

 

 

/

Check here if another insurance company has made payment to you, another insurer or the doctor’s office.

If so, attach a copy of the statement showing payment.

Provider Information

Store or Dr Name

(

 

 

 

)

 

 

 

 

 

Store or Dr Phone Number

-

I acknowledge that the above-named provider is not a VSP Preferred Provider and that VSP cannot guarantee eye care and/or eyewear satisfaction. By signing this claim form, I certify that I have read the applicable claim fraud warnings included with this form, and that all the information I have provided above is complete and accurate.

Claimant Signature:

 

_________________________________________________

Date: ____/____/_____

VSP Vision care for life isPlanregistered trademark of Vision Service Plan.

rev 11/2018

©2015 Vision Se v ce

. All righ s reserved.

 

VSP Vision care for life is a registered trademark of Vision Service Plan.

rev 3/2015

FRAUD WARNINGS

Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, Minnesota, New Mexico, Ohio,

Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law.

Arizona: For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly presents false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Delaware, Idaho, Indiana and Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive an insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Florida: A person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud as provided in RSA 638:20.

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Oregon: Any person who knowingly presents a materially false statement of claim may be guilty of a criminal offense and may be subject to penalties under state law.

©2015 Vision Service Plan. All rights reserved.

 

VSP Vision care for life is a registered trademark of Vision Service Plan.

rev 11/2018

Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.

Texas: Any person who knowingly presents a false or fraudulent claim for penalty of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Vermont: Any person who knowingly presents a false statement of claim for insurance may be guilty of a criminal offense and subject to penalties under state law.

Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

©2015 Vision Service Plan. All rights reserved.

 

VSP Vision care for life is a registered trademark of Vision Service Plan.

rev 11/2018

How to Edit Vsp Reimbursement Form Online for Free

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It is easy to fill out the form with this detailed guide! Here's what you have to do:

1. First, when filling in the vsp claim forms, start with the form section containing next fields:

Filling in part 1 in vsp out of network claim form 2021

2. The subsequent step is to complete all of the following fields: Date of Birth, Date services were received, Check here if another insurance, First Name, Last Name, Member, Spouse, Child, Domestic Partner, If the patient is a child over the, Is the child a fulltime student, Yes, Is the child disabled, Yes, and Claim Information Dollar amounts.

vsp out of network claim form 2021 completion process explained (portion 2)

3. Completing form I certify that I have read, Claimant Signature Date, and VSP Vision care for life is a is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Claimant Signature Date, form I certify that I have read, and VSP Vision care for life is a in vsp out of network claim form 2021

People often make errors when filling in Claimant Signature Date in this area. Be sure you re-examine whatever you type in right here.

Step 3: When you have looked once again at the information provided, just click "Done" to complete your form. After setting up afree trial account at FormsPal, you will be able to download vsp claim forms or email it at once. The document will also be at your disposal via your personal account with your each edit. With FormsPal, you can easily fill out forms without needing to worry about data leaks or records being shared. Our secure system helps to ensure that your personal details are kept safe.

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