Out-Of-Network Reimbursement Form

Submit this  form  along with  your **itemized receipt to: VSP P.O. Box 997105, Sacramento, CA 95899-7105

IMPORTANT NOTE:
Your  itemized receipt must include the information shown below with  an **· If your  receipt does not contain this  information your  claim  cannot be processed and  you will need to contact your  non-VSP provider for a new receipt which includes the required information.

Member Information:

Member's ID  or Social Security Number: 	_
Member's Name: 	_	Date of  birth: 	_ Address: 	  _

City:. 	

State: 	_	ZIP Code: 	_	Phone Number: 	_

Patient Information:

**Patient's Name: 		_   Date of Birth: 	_ Relationship to Member: 	_
If the  patient is a child (and over the  age  of 18):

Is the child a full time student?   Y/N Is the child physically impaired?  Y/N

Name of School: 	_

Reimbursement Request Information:

**Date Services were received: 	_

**Services received (please circle any  that apply and provide the  amount paid for each)

Exam
Lenses: Single Vision Bifocal Trifocal Progressive Lenticular
Lens Options:
Tint

$. 	_

$. 	_

$. 	_

Frame

Other 	$. 	_
(Includes Scratch Coatings, Anti-Reflective coatings, etc.)
$ 	_

Contact Lenses

Contact  fitting&/ or Evaluation

$. 	_

$. 	_

**Provider/Optical Shop  Name:. 	_

Address:. 	_

Phone Number: 	_

City: 	State: 	_	ZIP Code: 	_

For additional information on your eyecare benefits, please contact Customer Service at (800) 877-7195.

VSP OUT-OF-NETWORK REIMBURSEMENT DIRECTIONS

Please complete the form, attach your itemized receipts and mail to: VSP
P.O. Box 997105
Sacramento, CA 95899-7105

Important Note:
In order to process your claim the following information must be provided by the non­ VSP provider on the itemized receipt. Your claim cannot be processed if this information is missing.

•	the name of the provider
• 	the name of the patient
•	the date of service
•	a complete description of each service provided (exam, lens, frame or contacts)
•	the amount paid for each service

By enclosing the request for reimbursement form along with your itemized receipt your claim payment is expedited as it ensures we have all of the necessary information. It is important to note that the form is not a substitute for the items listed above, which must be included on the actual itemized receipt from the non-VSP provider. If these items are not on your receipt, you will want to contact your non­ VSP provider to obtain a new receipt containing the required information.

Should you have any questions, please contact Customer Service at (800) 877-7195.