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Click ‘Get Form’ to open the VSP Claim Form in the editor.
Begin by filling out the Member Information section. Enter your Policyholder/Employee ID or the last four digits of your SSN, followed by your first name, last name, date of birth, address, and daytime phone number.
Next, provide Patient Information. Indicate whether the patient is a member, spouse, child, or domestic partner. If applicable, answer questions regarding full-time student status and disability for children over 18.
In the Claim Information section, input dollar amounts for each service received (e.g., exam, lenses). Ensure these amounts match your attached receipts. Also, indicate if another insurance company has made a payment.
Complete the Provider Information by entering the store or doctor's name and phone number. Finally, sign and date the form to certify that all information is accurate.
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Other key differences can be seen in the low copays on your eye exam and glasses, a frame allowance, and discounts on lens enhancements. Your VSP vision plan coverage will go further when you see a VSP network doctor. With out-of-network providers, you may only be reimbursed a portion of your out-of-pocket cost.
How long does it take to submit a VSP claim?
You typically have 12 months from the date of service to submit for reimbursement. Failure to submit your out-of-network claim within 12 months of the date of service may cause your claim request to be denied.
What does VSP insurance actually cover?
Everyone on your plan gets the comprehensive vision coverage youd expect, like eye exams, glasses and savings on lens upgrades. Plus, with VSP EasyOptions, you and your dependents can each choose from a variety of covered upgrades during their in-network doctors visit. Look for the EasyOptions banner to learn more!
How do I submit a claim for VSP?
When you visit an in-network provider, no claim forms are needed. But, if you go out-of-network, you can submit a claim for reimbursement online from your VSP member account or by contacting VSP Member Services at 800.877.7195 and requesting a claim/reimbursement form.
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Jan 14, 2016 All claim forms must be signed and dated. Mailing Addresses for Submission of Claims: Santa Clara Family Health Plan. P.O. Box 18640. San Jose,
UMP (PEBB) Vision Service Plan (VSP) reimbursement form
VSP MEMBER REIMBURSEMENT FORM. To request reimbursement, complete and print this form, enclose a legible copy of your itemized receipt(s), and send them to
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.
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