Vsp Out Of Network Reimbursement Form

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Out-Of-Network Reimbursement Form
Member Information
member’s name _____________________ date of birth _____________
address _____________________________________________
city ________________________
state ___
ZIP _________
member’s ID or SSN ______________________________
name of group/employer ____________________________________
Patient Information
patient’s name _____________________ date of birth ____________
relationship to member _______________
if the patient is a child (and over the age of 18):
[] Is the child a full time student?
[yes] [no] name of school _______________
[] Is the child physically impaired? [yes] [no]
Reimbursement Request Information
date services were received ________________
services received (circle any that apply and provide the amount paid for each)
exam
$________________
lenses
single vision
bifocal
trifocal
$________________
progressive
lenticular
lens options
tint
$_________________
other*
$_________________
*(includes scratch coatings, anti-reflective coatings, etc.)
frame
$_________________
contact lenses
$_________________
contact fitting &/or evaluation $_________________
provider/optical shop ____________________
phone ___________
address _____________________________________________
city ________________________
state ___
ZIP _________
Submit this form along with related receipts to
VSP
P.O. Box 997105
Sacramento, CA 95899-7105
For more information on your eyecare benefits, please visit

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