Vision request reimbursement: Fill out & sign online

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01. Edit your vision request reimbursement online

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02. Sign it in a few clicks

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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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