Vsp Reimbursement Form – Fill Out and Use This PDF

Under Member Information, enter the Policyholder/Employee ID or Last 4 Digits of SSN, Date of Birth, First Name, Last Name, Address, Apt, City, State, Zip, Daytime Phone # and Employer/ Group.

Under Patient Information, enter First Name, Last Name, Member, Spouse, Child or Domestic Partner, and Date of Birth.

If the patient is a child over the age of 18: Is the child a full-time student? Yes No Is the child disabled? Yes No. Claim Information (Dollar amounts must match the attached receipts). Lens Type: (Choose One) Single, Progressive, Bi-focal, Lenticular, Tri-focal, Contacts. Date services were received. Enter Exam $, Frame $, Lens $, Lens tints $ or coatings, Contacts $ and Total Paid $. (Do not add tax or shipping) 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.

Under Provider Information, enter the Store or Dr Name and the Store or Dr Phone Number.

By signing this claim form, you certify that you have read the applicable claim fraud warnings included with this form, and that all the information you have provided is complete and accurate.

You acknowledge that the named provider is not a VSP Preferred Provider and that VSP cannot guarantee eye care and/or eyewear satisfaction.

Sign on the Claimant Signature line and enter the Date.

To request reimbursement, complete this form (in blue or black ink), enclose a legible copy of your itemized receipt(s), and send them to VSP PO Box 385018 Birmingham, AL 35238-5018.

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.