VSP Out-of-Network Reimbursement Form - Intuit Benefits 2026

1. Click ‘Get Form’ to open the VSP Out-of-Network Reimbursement Form in our editor.
2. Begin by entering the VSP Member’s Name, ID or Social Security Number, and Mailing Address in the designated fields.
3. Fill in the Employer/Health Plan and Member’s Date of Birth. Next, provide the Patient’s Name and Date of Birth. If there are multiple claims, ensure each patient is listed accordingly.
4. Indicate the Patient’s Relationship to the Member. If applicable, specify if the child is a full-time student and whether they are physically impaired.
5. Select the Date services were received and check off the appropriate services received (Exam, Lenses, Frame, Contacts). Be sure to attach an itemized statement of service costs.
6. Complete Provider’s Name, Address, and Telephone Number fields. If coordinating benefits with another insurance carrier, include a copy of their Explanation of Benefits.
7. Finally, attach your claim/receipt to this form and mail it to VSP at the provided address.

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