Work with Vision Care

Provider Information

Provider First Name

Middle Initial

Provider Last Name

Select Suffix

Provider Date of Birth (MM/DD/YYYY)

Ethnicity

American Indian or Alaskan Native Asian/Pacific Islander Black/African American Caucasian Hispanic or Latino Other I choose not to disclose

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 (If Different From Above)

Contact Name

Contact Email (If Different From Above)

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

How many locations do you own?

Are you employed at any other location?

Yes No

How many frames do you have on display in your dispensary?

Are contact lenses dispensed at this office?

Yes No

What percentage of the practice do you own?

What percentage of the dispensary do you own?

What is the business structure?

Sole Prop S-Corp Prof. Corp PLLC General Partnership (LLP)

What is the number of hours you work at this location?

Submit