Download VSP Claim Form

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As the largest supplier of vision insurance in the U.S., VSP provides a number of plans to reduce the costs of services like eye exams and obtaining prescription lenses. If you use a service outside of VSP’s network, you must submit an out-of-network VSP claim form to VSP.

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When to Use an Out-of-Network Claim Form

On the “Benefits & Claims” section of VSP’s website, you can find out whether your plan covers services from providers outside VSP’s network. If your plan does cover these providers, you may see one and then submit the out-of-network form to be reimbursed for the cost. You can find the form on VSP’s website and submit it at the Benefits & Claims section, along with receipts, or you can mail them. Often, employers will have a specific form they prefer you to use for any out-of-network claims.

You have 6 months from the date of the service to submit the form for reimbursement. Processing the claim can take up to 10 days, in addition to the time it takes the form to arrive if mailed.

If you are seeing a doctor within VSP’s network, there is no need to fill out any form. The doctor’s offices will complete the paperwork for VSP and obtain payment from the network, and you will only pay the out-of-pocket costs your plan specifies for the service.

Completing the Form

Completing most out-of-network VSP forms is simple. At the top, you will enter member information such as name, member number, Social Security number, DOB, and address. If your child, relative, or spouse has used vision services, your VSP coverage may pay for that service, and you would need to fill out the section asking for the patient’s identifying information, as well as the patient’s relationship to you (spouse, child, etc.).

In the last section, you’ll have to enter the cost of the services, itemized according to lens type, lens coating, lens cost, lens tint, contacts cost, frame cost, or the cost of the exam. You then have to fill in the name of the provider, their address and phone number, date of services, and usually you will have to sign and date the form, attesting that the information is accurate.

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