Missing information and receipts can delay your reimbursement. Fill out the form completely and if you're filling it out online, snap a legible picture of your receipt and attach it to your claim to get …

Write the amount of the Laser Vision Care claim under “Exam” on the reimbursement form.

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.

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.

For patients identified as participating in a flexible spending account on the VSP Patient Record Report, enter the total amount paid by the patient including any non-covered services.

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.

Find information on how to submit a claim for in-network reimbursement or out-of-network reimbursement with VSP.

If you are coordinating benefits with another insurance carrier, we need a complete copy of the Explanation of Benefits from your primary insurance carrier. The Explanation of Benefits must …

View the VSP Request for Reimbursement Form in our collection of PDFs. Sign, print, and download this PDF at PrintFriendly.

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.