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You don’t need to fill out a claim form when you see a VSP network eye doctor or provider. The doctor or provider will submit the claim directly to VSP for processing after your appointment. The doctor or provider will discuss any copays or out-of-pocket expenses with you during your appointment.
- Submit an Out-of-Network Claim
Submit an Out-of-Network Claim. If you've received eye care...
- FAQs Claims and Reimbursement
If you are no longer a VSP member and are in need of...
- Submit an Out-of-Network Claim
To request reimbursement, complete this form (in blue or black ink), enclose a legible copy of your itemized receipt(s), and send them to the following address. Be sure to keep a copy for your records.
If you received eye care services from an out-of-network provider, you can request partial reimbursement by filling out this form and attaching your receipts. You need to provide the name of the provider, patient, date of service, and description and amount of each service.
If you are no longer a VSP member and are in need of submitting a claim, please contact Member Services at 800.877.7195 to receive a Member Reimbursement form (VSP out-of-network form). Once you have received the form, please send the completed form to Vision Service Plan, attention Claims Services PO Box 495918 Cincinnati, OH 45249-5918.
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 **.
VSP Member Reimbursement Form. To request reimbursement, complete and print this form, enclose a legible copy of your itemized receipt(s), and send them to the following address. Be sure to keep a copy for your records. VSP PO Box 495918 Cincinnati, OH 45249-5918 Member Spouse Domestic Partner Child Dependent Parent
Download and print a fillable form to request reimbursement for out-of-network vision care services. Follow the instructions and tips to complete the form and mail it to VSP with your receipts.
