Vsp Claim Form - County Information Resources Agency
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1VSP 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 997105
Sacramento, CA 95899-7105
Ref #
Ref
Member Information
/
/
Member's ID or Last 4 Digits of SSN
Date of Birth
First Name
Last Name
Last Name
Address
Apt
City
State
Zip
Employer /
)
(
Group
_______________________________________________
-
Daytime Phone #
Patient Information
First Name
Last Name
Domestic
/
/
Member
Spouse
Child
Partner
Date of Birth
If the patient is a child over the age of 18:
Yes
No
Yes
No
Is the child a full-time student?
Is the child disabled?
Claim Information (Dollar amounts must match the attached receipts)
Date services were received
Lens Type: (Choose one)
.
$
Exam
/
/
Single
Progressive
.
$
Frame
Check here if another insurance
Lenticular
Bi-Focal
.
company has made payment to you,
$
Lens
another insurer or the doctor’s office
.
Check here another insurance
company has made payment to
If so, attach a copy of the statement
.
Lens tints
$
Tri-Focal
Contacts
showing payment
you, another insurer or the
or coatings
doctor’s office
.
$
Contacts
.
$
Total Paid
(Do not add tax or shipping)
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 my
eyecare and/or eyewear satisfaction. I also attest that the information I have provided above is complete and
accurate.
I fully understand and consent to the above statement: __________________________________ Date: ________
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