Vsp Out-Of-Network Reimbursement Form

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NOTE: All claims must be submitted within 6 months of date services were received
Out-Of-Network Reimbursement Form
Member Information:
Member’s Name:________________________________
Date of Birth:____________________
Address:_______________________________________
City:______________________________ State:_______ ZIP Code:____________
Member’s ID or Social Security Number:___________________________________
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? Y/N
Name of School:_________________
Is the child physically impaired? Y/N
Reimbursement Request Information:
Date Services were received:_______________________
Services received (please 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 Name:_______________________
Phone Number:__________________
Address:_________________________________________
City:______________________________
State:_______
ZIP Code:________________
Coordination of Benefits Information:
If you are coordinating benefits with another insurance carrier, we need a complete copy of the Explanation of
Benefits from your primary insurance carrier. The Explanation of Benefits must indicate the service(s) which were
received, as well as the amount paid, denied, or applied to your deductible. This information can be obtained from
the provider who performed your recent services.
Submit this form along with related receipts to:
VSP
P.O. Box 997105
Sacramento, CA 95899-7105
For additional information on your eyecare benefits, please visit our website at:

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