___________________________________________________ _______________
VSP COMPUTER VISION GLASSES CONFIRMATION FORM
For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or
fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in prison.
The VSP Computer Vision Care (CVC) Confirmation Form is only provided to CSU employees who meet the
necessary job requirements as determined by the CSU campus benefits office. This form must be completed by
the employee and provided to a VSP Advantage Network doctor to receive the supplemental CVC benefit. Please call
VSP Member Services at 800-877-7195 if you have questions about the benefit.
INSURED TO COMPLETE AND SIGN THIS SECTION
Employee’s Name (Last Name First) Last 4 Digits Of Social Security
Gender
Number
Male Female
Street Address Employee’s Birthdate
City, State, and Zip Code
General Visual Information
1. Time spent at computer? _________ Hours per day.
2. Work is performed while:
Sitting Other (please describe):
3. Job Title: ____________________________________________________________
4. Lighting in work area (Please describe): ____________________________________________
Are you experiencing any of the following symptoms while at your computer? Check all which apply.
Headaches
Blurred Near Vision Blurred Distant Vision Slowness in Focusing (Distant to near and back)
Double Vision
Sore or Tired Eyes (Strain) Glare (Light) Sensitivity
Dry or Watery Eyes
Burning, Itching or Red Eyes
Neck and Shoulder Pain
Back Pain
Do you wear glasses while working at the computer?
YES NO Please bring them with you to the examination
Do you wear contacts while working at the computer? YES NO Please bring them with you to the examination
Do you reference material while working at the computer? YES NO What percentage of time?
In order for the doctor to accurately assess your occupational vision needs and possible appropriate eye wear, the following
distances/direction must be completed:
Viewing distance eye to computer screen is ____ inches. Viewing distance eye to keyboard is ____ inches.
Viewing distance eye to reference material is ____ inches.
The center of the screen is:
above equal to below eye level If above or below, by how many inches? ____
Reference material is: above equal to below eye level If above or below, by how many inches? ____
The above answers are true and complete according to the best of my knowledge and belief. By signing this form, I hereby
certify that my CSU job requires me to use a computer four or more hours per day on a regular, ongoing basis.
I understand that if I obtain services and do not meet these CVC eligibility requirements, I will be responsible for any and all
charges incurred. I hereby assign payable benefits to participating providers.
Employee Signature Date
OUT OF NETWORK INSTRUCTIONS:
Dollar for dollar you get
the best value from your benefit when using a VSP Advantage Net work doctor. If you decide to use a non-VSP Provider, the $10 exam copay
still applies, and you’ll receive a lesser benefit and t ypically pay more out-of-pocket. You are also required to pay the provider in full at the time of your appointment
and submit to the mailing address below both a copy of the this form and itemized receipt to VSP for partial reimbursement based on the plan allowances.
VSP
PO Box 385018
Birmingham, AL 35238-0518
Attn: Out-of-Network Claims
Group Number 30059426 9/2016
