Get Vsp Out Of Network Reimbursement Form - Dgaplans.org - Dgaplans

Filling out the VSP Out Of Network Reimbursement Form can help you claim reimbursement for vision care services received outside your network. This guide provides a step-by-step approach to accurately complete the form and submit it for processing.

Follow the steps to efficiently complete the reimbursement form.

1. Press the ‘Get Form’ button to access the reimbursement form you need to complete.
2. Enter your member information, including your ID or Social Security Number, name, date of birth, address, email address, city, state, ZIP code, and phone number. Make sure all information is accurate to avoid any delays in processing.
3. Fill out the section for patient information. Include the patient’s name, date of birth, and relationship to you. If the patient is a child over the age of 18, indicate if they are a full-time student and provide the name of the school. Also, check if the child is physically impaired, answering yes or no as applicable.
4. In the reimbursement request information section, provide the date services were received. Circle the services you received from the options listed and input the amounts paid for each service.
5. Complete the section regarding frame and contact lenses if applicable, indicating the amounts paid for these items.
6. List the name, phone number, and address of the provider or optical shop where the services were received.
7. Review all sections to ensure completeness and accuracy. Once verified, you can save the changes, download, print, or share the completed form.

Complete your VSP Out Of Network Reimbursement Form online today!