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How to use or fill out VSP Out-of-Network Reimbursement Form - Intuit Benefits with DocHub
- Click ‘Get Form’ to open the VSP Out-of-Network Reimbursement Form in our editor.
- Begin by entering the VSP Member’s Name, ID or Social Security Number, and Mailing Address in the designated fields.
- 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.
- 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.
- 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.
- Complete Provider’s Name, Address, and Telephone Number fields. If coordinating benefits with another insurance carrier, include a copy of their Explanation of Benefits.
- Finally, attach your claim/receipt to this form and mail it to VSP at the provided address.
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