01. Edit your vision request reimbursement online
Type text, add images, blackout confidential details, add comments, highlights and more.
Request For Reimbursement Request For Reimbursement 2026
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02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send vsp request reimbursement via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out Request For Reimbursement Request For Reimbursement with our platform
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- Click ‘Get Form’ to open it in the editor.
- Begin with the Patient section. Select the patient's relation to the member and enter their date of birth in the format Month/Day/Four-Digit Year. Choose a gender and fill in the patient's last name, first name, address, city, state, and ZIP code.
- In the Member section, enter the Last 4 Digits of the member's SSN or unique ID number. If applicable, check 'Member information below is the same as Patient.' Otherwise, provide the member's date of birth and personal details.
- Proceed to the Claim section. Enter the Date of Service and ensure that amounts charged match your receipts. Select a Lens Type if applicable.
- Complete the Provider section by entering known provider details including their name and office address.
- Finally, review all entries for accuracy, print, sign, and date the form before mailing it to VSP at the specified address.
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Related links
There are two ways to request reimbursement of eligible medical expenses: By form or online (non-insurance premiums only).Read more
To request employee reimbursement for University of Arizona active employees. Hotline: 1-866-364-1908