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Vsp claim form pdf 2026
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- Click ‘Get Form’ to open the VSP Member Reimbursement 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. Fill in their date of birth and answer questions regarding full-time student status and disability if applicable.
- 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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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2018 | 4.8 Satisfied (119 Votes) |
How do I file a claim with 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.
How to submit a corrected claim to VSP?
For claim corrections, such as a diagnosis code, billed amount or service code, call VSP at 800.615. 1883 or complete the claim correction form on eyefinity.com.
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.
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vsp claim form pdf download
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.Read more
VSP MEMBER REIMBURSEMENT FORM. To request reimbursement, complete and print this form, enclose a legible copy of your itemized receipt(s), and send them toRead more
Jan 1, 2021 Molina requires Providers to submit Claims electronically through a clearinghouse or. Molinas secure Provider Portal.Read more