Vsp claim form printable 2026

1. Click ‘Get Form’ to open the vsp claim form printable in the editor.
2. Begin by entering your Member Information. Fill in your ID or the last four digits of your Social Security Number, followed by your name, address, date of birth, city, state, ZIP code, and phone number.
3. Next, provide Patient Information. Enter the patient's name and their relationship to you. If the patient is a child over 18, indicate if they are a full-time student or physically impaired and include their school name if applicable.
4. In the Reimbursement Request Information section, specify the date services were received and circle any services that apply (e.g., Exam, Lenses) while providing the amount paid for each service.
5. Lastly, fill in the Provider/Optical Evaluation details including shop name, address, city, state, ZIP code, and phone number.

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