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 your …

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.

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.

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.

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

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

VSP Member Reimbursement Form 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 …

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.