Visual presentation of this web site requires JavaScript.
Skip to main content
Choose Language
 

Patient Rights

Authorization to Use or Disclose Protected Health Information Form

Use the Authorization to Use or Disclose Protected Health Information Form  (also known as an appointment of a representative) form when you want VSP to share your information over the telephone with your representative, such as a spouse, relative, or law firm.

Your information may include:

  • Claims
  • Claims adjudication information
  • Eligibility/benefit information
  • Provider information

Note: This form does not include release of your mental health/substance abuse/HIV claims and authorization information, or genetic information.

This form must be completed by the member (or authorized representative) and must include an expiration date. If no expiration date is specified, this authorization will expire 24 months from date of signature.

Requests take 7-10 business days from date of receipt to process.

You will not be notified of approval. Denied forms will be returned to the member.

Send completed forms to:

VSP
Attn: Regulatory Compliance
3333 Quality Drive
MS-163
Rancho Cordova, CA 95670
HIPAA@vsp.com

Patients' Appeal Rights

You have the right to appeal if:

  • You do not agree with VSP's decision about your health care.
  • VSP will not approve or give you care you feel it should cover.
  • VSP is stopping care you feel you still need.

VSP normally has 30 days to process your appeal. In some cases, you have a right to a faster, 24-hour appeal. You can get a fast appeal if your health or ability to function could be seriously harmed by waiting 30 days for a standard appeal. If you ask for a fast appeal, VSP will decide if you get a 24-hour/fast appeal. If not, your appeal will be processed in 30 days. If any doctor asks VSP to give you a fast appeal, or supports your request for a fast appeal, it must be given to you.

If you want to file an appeal which will be processed within 30 days, do the following:

File the request in writing with VSP at the following address:
Vision Service Plan
Attn: Appeals Department
P.O. Box 2350
Rancho Cordova, CA 95741 

Even though you may file your requests with VSP, VSP may transfer your request to the appropriate agency for processing. Your appeal request will be processed within 30 days from the date your request is received.

If you want to file a fast appeal, which will be processed within 24 hours, do the following

  • File an oral or written request for a 24-hour appeal. Specifically state that "I am requesting an: expedited appeal, fast appeal or 24-hour appeal." Or "I believe that my health could be seriously harmed by waiting 30 days for a normal appeal."
  • To file a request orally, call 800-877-7195. VSP will document the oral request in writing.

Help with your appeal:

If you decide to appeal and want help with your appeal, you may have your doctor, a friend, lawyer, or someone else help you. There are several groups that can help you. If you are covered by Medicare, you may contact the Medicare Rights Center toll free at 888-HMO-9050. You may also contact the National Aging Information Center at (202) 619-7501 to request the phone number of your local Area Agency on Aging or health Insurance Counseling and Assistance Program (HICAP).

Patient Rights and Responsibilities

You have the right to be treated with consideration, dignity, respect and to have VSP network doctors:

  • Provide you with complete information about your eyecare and any proposed procedures and alternatives regardless of cost or benefit coverage.
  • Assure that you control decisions about your eyecare treatment.
  • Provide 24-hour access for ocular emergencies.
  • Maintain privacy and confidentiality regarding your care.
  • Make available to you appropriate preventive health services.
  • Give prompt and reasonable responses to questions and requests.
  • Provide information regarding their services and qualifications.
  • Provide you with VSP grievance procedures if there is dissatisfaction with services.
  • Obtain your input regarding services and assist you with any problems.

Your responsibility is to remember to practice healthy living habits, follow preventive health and eyecare guidelines, and:

  • Check the health care benefits and exclusions of your coverage.
  • Establish and maintain a relationship with your primary eyecare provider.
  • Give your eyecare providers complete and accurate information needed in order to care for you.
  • Notify your eyecare provider if you are going to be late or need to reschedule an appointment.
  • Know the cost (co-payment, deductible, coinsurance) of your care.
  • Carry out the treatment plan agreed upon by you and your eyecare provider or primary care physician.
  • Know how to access urgent, emergency and out-of-area medical eyecare services.

Request for Accounting of Disclosures

Requests for accounting of disclosures must be submitted in writing and include the member’s name, date of birth, member ID, address, telephone number, email (if available), and the time frame for the accounting. If a request is submitted on behalf of a member, an authorization to disclose or other legal documentation, such as a power of attorney or custody documents, must be submitted with the request.

VSP provides an accounting for protected health information disclosed in the six years prior to the date on which the accounting is requested (electronic health records disclosed three years prior to the date on which the accounting is requested).

VSP doesn’t provide an accounting for disclosures:

  • to carry out treatment, payment, and healthcare operations
  • to individuals of protected health information about them
  • incident to a use or disclosure otherwise permitted or required
  • pursuant to an authorization
  • for the VSP member directory or to persons involved in the individual's care or other notification purposes
  • for national security or intelligence purposes
  • to correctional institutions or law enforcement officials
  • as part of a limited data set

VSP will respond to your request no later than 60 days after we receive your request.

Submit your requests to:
VSP
Attn: Regulatory Compliance
3333 Quality Drive
MS-163
Rancho Cordova, CA 95670
HIPAA@vsp.com

Request for Amendment of Protected Health Information

If you feel your health records are incomplete or inaccurate, you have the right to request an amendment or correction to your protected health information. VSP will respond to all requests to amend. However, VSP doesn’t create patient medical or billing records and generally can’t grant an amendment. In most cases, VSP will direct you to submit the request to the provider or facility that rendered care.

Requests for amendment must be submitted in writing and you’ll need to provide a reason to support the amendment. Requests can be submitted to:

VSP
Attn: Regulatory Compliance
3333 Quality Drive
MS-163
Rancho Cordova, CA 95670
HIPAA@vsp.com

VSP will respond to your request no later than 60 days after we receive your request.

Note: A request to correct member profile errors, update demographic information, or correct billing or processing errors isn’t considered a request for amendment. To address these types of requests: call 800.877.7195 to speak with Member Services:

Monday - Friday 5 a.m. to 8 p.m., Pacific Time
Saturday 7 a.m. to 8 p.m., Pacific Time
Sunday 7 a.m. to 7 p.m., Pacific Time
Closed Thanksgiving Day and Christmas Day

Hearing impaired customers may call 800.428.4833 for assistance.

Request for Records Form

Use the Request for Records Form (also known as a request to access protected health information) to request copies of member records maintained by VSP.

Records maintained by VSP include:

  • Claims
  • Complaints/appeals you have filed
  • Authorization for Use and Disclosure forms you have submitted

Note: This form does not include release of mental health/substance abuse/HIV claims and authorization information, or genetic information.

Section 3 (dates of coverage/service) must be completed. Forms without dates of service will be returned.

This form must be completed by the member (or legal representative).

Send completed forms to:

VSP
Attn: Regulatory Compliance
3333 Quality Drive
MS-163
Rancho Cordova, CA 95670
HIPAA@vsp.com

Create an account on vsp.com for instant access to your personal benefit information. Call VSP Member Services at 800.877.7195 to request eligibility and benefit information or an out of pocket expense summary.

Hours of Operatiovns:
Monday - Friday 5 a.m. to 8 p.m., Pacific Time
Saturday 7 a.m. to 8 p.m., Pacific Time
Sunday 7 a.m. to 7 p.m., Pacific Time
Hearing impaired customers may call 800.428.4833 for assistance.
Closed Thanksgiving Day and Christmas Day

Request to Restrict Use and Disclosure of Protected Health Information

If you could be at risk of harm, harassment, or abuse when your health information is shared, you have the right to request VSP restrict how protected health information (PHI) about you is used or disclosed.

VSP implements restrictions of PHI through its Protected Member Confidentiality Program. VSP members may request a restriction by completing the Request for Restriction of Use and Disclosure of Protected Health Information and Confidential Communications form. VSP will respond to your request no later than 14 business days after we receive your request.

Submit your requests to:
VSP
Attn: Regulatory Compliance
3333 Quality Drive
MS-163
Rancho Cordova, CA 95670
HIPAA@vsp.com

Right to Request Confidential Communications

If you could be at risk of harm, harassment, or abuse when your health information is shared, you have the right to request VSP send your protected health information (PHI) to you at an alternative address.

VSP implements alternative addresses through its Protected Member Confidentiality Program. VSP members may request an alternative address be used when sending PHI by completing the Request for Restriction of Use and Disclosure of Protected Health Information and Confidential Communications form available on vsp.com.

VSP will make every effort to send all claim and billing information containing PHI related specifically to you, including dates of services received and the name of the provider of services, to the alternative address you provide.

VSP will respond to your request no later than 14 business days after we receive your request.

Submit your requests to:
VSP
Attn: Regulatory Compliance
3333 Quality Drive
MS-163
Rancho Cordova, CA 95670
HIPAA@vsp.com


Are you a Rhode Island resident?
If so, click here to view the Rhode Island Consumer Disclosure summary.