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Click ‘Get Form’ to open the Vision Eye Care Claim Form in the editor.
Begin by filling out the 'Patient and Subscriber Information' section. Enter the patient's name, date of birth, and subscriber's name accurately. Ensure you include any other insurance information if applicable.
Indicate the patient's sex and relationship to the subscriber. Fill in the subscriber's ID number and group number as shown on their insurance card.
In the next section, specify if the condition was due to work or an auto accident. If yes, provide additional details as required.
Complete the authorization section by signing and dating where indicated. This confirms that all provided information is correct.
If you are a provider completing this form, ensure items 13 through 36 are filled out accurately, including diagnosis codes and service details.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (65 Votes)
2014	4.3 Satisfied (67 Votes)
2009	4 Satisfied (50 Votes)

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How many pairs of glasses does VSP cover?

If your frames are broken or damaged within 12 months from the date of purchase return them to your Premier Program location. Your doctor will replace them free of charge, no questions asked. If both your frame and lenses break, you can replace your lenses and any lens enhancements at special warranty pricing.

How to submit a vision insurance claim?

If you visit a non-network provider, submit a claim online by requesting an online claim form link or complete a paper form and mail it to the address listed on the form. Refer to the EyeMed Vision Out of Network Claim form for instructions on requesting an online claim form link.

How do I submit a claim to VSP for glasses?

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.

How long do I have 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.

How to get reimbursed for an eye exam?

If you dont see your provider below, you can download a form on your insurance companys website. Attach Your Itemized Receipt. Well include a receipt with your package when you receive them. Submit The Claim Form And Receipt To Your Vision Insurance Company. Collect Your Reimbursement!