Work with Vision Care

Provider Information

Provider First Name

Middle Initial

Provider Last Name

Select Suffix

Provider Date of Birth (MM/DD/YYYY)

Race and Ethnicity

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Middle Eastern or North African Native Hawaiian or Other Pacific Islander White Prefer not to say I do not have the information to answer

If you wish to add more than one additional language, please email providernetworkdevelopment@vsp.com.

Languages you speak (Other than English )

Provider Email

Provider Gender

Male Female Other

NPI Type 1 Number

Provider Type

Optometrist (must be TPA certified, except in Puerto Rico) Doctor of Osteopathic Medicine (must be board certified) Ophthalmologist (must be ABO board certified) Other

Special services offered by doctor:

Children 0-3 years Children 3-5 years Hard-to-fit contact lenses Low vision Vision Therapy None

Primary Practice Information

Practice Name* (IRS Registered Name)

Practice Email

Contact Name

Contact Email

Physical Street Address

Physical City

State

Physical Zip

Office Phone Number

Office Fax Number

Contact Phone Number

NPI Type 2 Number

Tax ID

Medicare Number

CMS Application Submission Date (MM/DD/YYYY)

Are you a registered provider with Medicaid and accepting patients?

Do you have your own professional liability insurance of at least $1 million per occurrence / $3 million aggregate?

Yes No

Are you registered with CAQH? (Council For Affordable Quality Healthcare)?

Yes No

Are you a US Veteran?

Yes No

Additional Comments

Are you: (check all that apply)

Employed by another doctor? Owner of your own practice and/or in the process of purchasing an existing practice?

DO YOU WORK AT ADDITIONAL VSP LOCATIONS?

Yes No

DO YOU WORK AT MORE THAN 10 VSP LOCATIONS?

Yes No

Location 1

Tax ID

Physical Office Address

City

State

Zip

Location 2

Tax ID

Physical Office Address

City

State

Zip

Delete

Location 3

Tax ID

Physical Office Address

City

State

Zip

Delete

Location 4

Tax ID

Physical Office Address

City

State

Zip

Delete

Location 5

Tax ID

Physical Office Address

City

State

Zip

Delete

Location 6

Tax ID

Physical Office Address

City

State

Zip

Delete

Location 7

Tax ID

Physical Office Address

City

State

Zip

Delete

Location 8

Tax ID

Physical Office Address

City

State

Zip

Delete

Location 9

Tax ID

Physical Office Address

City

State

Zip

Delete

Location 10

Tax ID

Physical Office Address

City

State

Zip

Delete

Submit

Before You Start Checklist

Work with Vision Care

Before You Begin: Confirm You Have Everything You Need