"Out of Network Reimbursement Form - Vsp" - California

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Download "Out of Network Reimbursement Form - Vsp" - California

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Clear Form
Out-Of-Network Reimbursement Form
Coordination of Benefits Information:
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 indicate the service(s) which were received, as well as the amount paid,
denied, or applied to your deductible. This information can be obtained from the provider who performed your recent services.
Member Information:
Member’s ID or Social Security Number:___________________________________
Member’s Name:_______________________________________________________
Date of Birth:__________________
Address:_______________________________________________________________
E-Mail Address:________________
City:______________________________ State:_______ ZIP Code:____________
Phone Number:________________
Name of Group/Employer:______________________________________________
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
Name of School:_____________________________________
Is the child physically impaired? Y /N
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
$_________________
*Other
$_________________
*(Includes Scratch Coatings, Anti-Reflective coatings, etc.)
Frame
$_________________
Contact Lenses
$_________________
Contact fitting &/or Evaluation
$_________________
Provider/Optical Shop Name:___________________________________
Phone Number:__________________
Address:_____________________________________________________
City:__________________________________________ State:_________
ZIP Code:______________________
Submit this form along with related receipts to:
VSP
P.O. Box 997105, Sacramento, CA 95899-7105
For additional information on your eyecare benefits, please visit our website at: VSP.com
Clear Form
Out-Of-Network Reimbursement Form
Coordination of Benefits Information:
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 indicate the service(s) which were received, as well as the amount paid,
denied, or applied to your deductible. This information can be obtained from the provider who performed your recent services.
Member Information:
Member’s ID or Social Security Number:___________________________________
Member’s Name:_______________________________________________________
Date of Birth:__________________
Address:_______________________________________________________________
E-Mail Address:________________
City:______________________________ State:_______ ZIP Code:____________
Phone Number:________________
Name of Group/Employer:______________________________________________
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
Name of School:_____________________________________
Is the child physically impaired? Y /N
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
$_________________
*Other
$_________________
*(Includes Scratch Coatings, Anti-Reflective coatings, etc.)
Frame
$_________________
Contact Lenses
$_________________
Contact fitting &/or Evaluation
$_________________
Provider/Optical Shop Name:___________________________________
Phone Number:__________________
Address:_____________________________________________________
City:__________________________________________ State:_________
ZIP Code:______________________
Submit this form along with related receipts to:
VSP
P.O. Box 997105, Sacramento, CA 95899-7105
For additional information on your eyecare benefits, please visit our website at: VSP.com