VSP Assignment of Benefits Form

Effective October 1, 2003, if you wish to submit a claim for benefits that have been assigned to you by your patient, you will need to submit with the claim a fully completed and signed VSP Assignment of Benefits Form.

The VSP Assignment of Benefits Form is provided below for you to download as a master copy. Please make copies and include a signed form with each claim submitted to VSP. Claims submitted without this completed and signed form will be paid directly to VSP's covered member.

Please follow these instructions when using the form:

• Use capital letters in the spaces provided on the form.
• Fill out the form completely and make sure all applicable boxes are checked.
• Submit the completed form and a copy of the itemized bill(s) for services to:
  

  VSP
  P.O. Box 997105
  Sacramento, CA 95899-7105

VSP Assignment of Benefits Form

To download, navigate and print the VSP Assignment of Benefits Form you will need the free Acrobat Reader software available from Adobe Systems Incorporated's Web site (http://www.adobe.com/products/acrobat/readstep2.html)