Vsp claim form pdf 2026

1. Click ‘Get Form’ to open the VSP Member Reimbursement Form in the editor.
2. 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.
3. 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.
4. 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.
5. 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.

Start using our platform today to easily fill out your VSP claim form for free!