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Submitted URL: https://click.e.vsp.com/?qs=62cd4474b5c9c4489e9b165a5909c8716cea00193ddbdb2a4be6ec254efd93709765e1b3caffac07a0044abff72a...
Effective URL: https://www.vsp.com/contact-us/email-customer-service?utm_confid=vlu3qjj18&kx_campaign=VC_T3_Ampsript_HTML+Refresh&s...
Submission: On September 28 via api from US — Scanned from DE
Effective URL: https://www.vsp.com/contact-us/email-customer-service?utm_confid=vlu3qjj18&kx_campaign=VC_T3_Ampsript_HTML+Refresh&s...
Submission: On September 28 via api from US — Scanned from DE
Form analysis 2 forms found in the DOM
<form novalidate="" vspvalidationcontainer="" class="header-search-input-form ng-untouched ng-pristine ng-star-inserted ng-invalid" aria-hidden="true"><label class="hidden-accessible" id="site-search-label"
for="site-search-input">Search</label><input placeholder="Search" name="query" minlength="3" maxlength="2048" pattern="^((?!(\d{9}|\d{3}-\d{2}-\d{4})).)*$" required="" tabindex="-1"
class="form-control header-search-input ng-untouched ng-pristine ng-invalid" id="site-search-input"><a href="" tabindex="-1"><i title="Close Search" class="d-none icon-close header-search-close"></i></a></form><form novalidate="" vspvalidationcontainer="" class="mb-5 ng-untouched ng-dirty ng-invalid">
<div class="d-flex flex-wrap"><span class="what-can-we-help-you-with-headline flex-sm-100">What can we help you with?</span><vsp-form-group label="What can we help you with?" messages="Please select a help reason."
class="what-can-we-help-you-with-select flex-sm-100 mt-4 mt-md-0">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><ng-select role="listbox" aria-label="What can we help you with" id="what-can-we-help-you-with" name="whatCanWeHelpYouWith" required="" bindvalue="value"
class="ng-select ng-select-single ng-select-searchable ng-untouched ng-pristine ng-invalid">
<div class="ng-select-container">
<div class="ng-value-container">
<div class="ng-placeholder">What can we help you with?</div><!----><!---->
<div class="ng-input"><input role="combobox" type="text" autocorrect="off" autocapitalize="off" autocomplete="a149cfc70679" id="what-can-we-help-you-with-ng-select-filter-input" aria-expanded="false"></div>
</div><!----><!----><span class="ng-arrow-wrapper"><span class="ng-arrow"></span></span>
</div><!---->
</ng-select></div><label class="vsp-form-group-label" id="what-can-we-help-you-with-label" for="what-can-we-help-you-with-ng-select-filter-input"> What can we help you with? </label><!----><vsp-validation-message
id="what-can-we-help-you-with-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group></div>
<div class="vsp-form">
<fieldset>
<legend class="form-section-header">Primary Member Information</legend><vsp-contact-us-member-info name="memberInfo" class="ng-untouched ng-pristine ng-valid">
<div class="row ng-star-inserted"><vsp-form-group class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="member-first-name" name="memberFirstName" required="" vspvalidatestandardtext="" maxlength="65" placeholder="First Name" class="form-control ng-untouched ng-pristine ng-invalid"></div><label class="vsp-form-group-label"
id="member-first-name-label" for="member-first-name"> First Name </label><!----><vsp-validation-message id="member-first-name-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="member-last-name" name="memberLastName" required="" vspvalidatestandardtext="" maxlength="65" placeholder="Last Name" class="form-control ng-untouched ng-pristine ng-invalid"></div><label class="vsp-form-group-label"
id="member-last-name-label" for="member-last-name"> Last Name </label><!----><vsp-validation-message id="member-last-name-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group label="Email" class="col-md-4 ng-star-inserted">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="email" name="email" required="" email="" placeholder="Email" class="form-control ng-untouched ng-pristine ng-invalid"></div><label class="vsp-form-group-label" id="email-label" for="email"> Email
</label><!----><vsp-validation-message id="email-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group label="Confirm Email" class="col-md-4 ng-star-inserted">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="confirm-email" name="confirmEmail" required="" placeholder="Confirm Email" class="form-control ng-untouched ng-pristine ng-invalid"></div><label class="vsp-form-group-label" id="confirm-email-label" for="confirm-email">
Confirm Email </label><!----><vsp-validation-message id="confirm-email-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><!----><!----><!----><vsp-date-picker label="DOB" id="birth-date" name="birthDate" class="col-md-4 ng-untouched ng-pristine ng-invalid ng-star-inserted" required="">
<div class="date-picker-container"><vsp-form-group>
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input type="text" name="date" ngbdatepicker="" maxlength="10" outsidedays="collapsed" placeholder="DOB" id="birth-date-datepicker" class="form-control ng-untouched ng-pristine ng-invalid" required=""><!----><vsp-tool-tip
label="Tooltip" class="date-picker-tooltip">
<div form-group-icon="">
<!----><i role="button" container="body" class="icon-tooltip d-none d-md-block" tabindex="0" aria-label="Tooltip"></i><!----><i role="button" triggers="click:blur" container="body" class="icon-tooltip d-md-none" tabindex="0" aria-label="Tooltip"></i><!---->
</div>
</vsp-tool-tip></div><label class="vsp-form-group-label" id="birth-date-datepicker-label" for="birth-date-datepicker"> DOB </label><!---->
<div form-group-icon=""><a role="button" aria-label="Toggle Calendar" aria-selected="true" aria-current="true" class="icon-calendar" href=""></a></div><vsp-validation-message id="birth-date-datepicker-validation"
class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group></div>
</vsp-date-picker><!----></div><!---->
</vsp-contact-us-member-info>
<div class="row-line-separator ng-star-inserted"></div><!----><vsp-ssn-and-member-id class="ng-untouched ng-pristine ng-valid ng-star-inserted">
<fieldset><!---->
<div ngmodelgroup="ssnOrMemberIdGroup" class="row ng-untouched ng-pristine ng-invalid"><vsp-form-group label="Last 4 of SSN" class="col-md-3">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="ssn" name="ssn" required="" vspvalidatenumbersonly="" maxlength="4" minlength="4" placeholder="Last 4 of SSN" class="form-control ng-untouched ng-pristine ng-invalid"><!----></div><label class="vsp-form-group-label"
id="ssn-label" for="ssn"> Last 4 of SSN </label><!----><vsp-validation-message id="ssn-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group>
<div class="create-account-input or-label">OR</div><vsp-form-group label="Member ID" class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="member-id" required="" name="memberId" vspvalidatealphanumericonly="" maxlength="30" placeholder="Member ID" class="form-control ng-untouched ng-pristine ng-invalid"><!----></div><label class="vsp-form-group-label"
id="member-id-label" for="member-id"> Member ID </label><!----><vsp-validation-message id="member-id-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group>
</div><vsp-validation-message class="d-block create-account-ssn-member-validation-message ng-star-inserted"><!----></vsp-validation-message><!----><!---->
</fieldset>
</vsp-ssn-and-member-id><!---->
</fieldset>
</div>
<div class="vsp-form"><vsp-contact-us-patient-info class="ng-untouched ng-pristine ng-valid">
<fieldset class="ng-star-inserted">
<div class="d-md-flex justify-content-start">
<legend class="form-section-header composite-legend">Patient Information</legend>
<div class="checkbox-header-wrapper"><vsp-checkbox-wrapper label="Same as primary member">
<div class="form-check form-check-checkbox"><input type="checkbox" id="sameAsPrimaryMember" name="sameAsPrimaryMember" class="ng-untouched ng-pristine ng-valid form-check-input"><label class="form-check-label"
for="sameAsPrimaryMember">Same as primary member</label></div><!---->
</vsp-checkbox-wrapper></div>
</div>
<div class="row"><vsp-form-group label="Patient First Name" content-before="" class="col-md-4 ng-star-inserted">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="patient-first-name" name="patientFirstName" required="" vspvalidatestandardtext="" maxlength="65" placeholder="Patient First Name" class="form-control ng-untouched ng-pristine ng-invalid"></div><label
class="vsp-form-group-label" id="patient-first-name-label" for="patient-first-name"> Patient First Name </label><!----><vsp-validation-message id="patient-first-name-validation"
class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><!----><!----><vsp-form-group label="Patient Last Name" content-before="" class="col-md-4 ng-star-inserted">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input id="patient-last-name" name="patientLastName" required="" vspvalidatestandardtext="" maxlength="65" placeholder="Patient Last Name" class="form-control ng-untouched ng-pristine ng-invalid"></div><label
class="vsp-form-group-label" id="patient-last-name-label" for="patient-last-name"> Patient Last Name </label><!----><vsp-validation-message id="patient-last-name-validation"
class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><!----><!----></div>
<div class="row-line-separator"></div><vsp-address labelprefix="Patient" name="patientAddress" class="d-block mb-3 ng-untouched ng-pristine ng-invalid" required="">
<div class="row"><vsp-form-group class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input name="address" vspvalidateaddresscitytext="" placeholder="Patient Address" id="patientaddress-address" class="form-control ng-untouched ng-pristine ng-invalid" required="" maxlength="65"></div><label
class="vsp-form-group-label" id="patientaddress-address-label" for="patientaddress-address"> Patient Address </label><!----><vsp-validation-message id="patientaddress-address-validation"
class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input name="city" vspvalidateaddresscitytext="" placeholder="Patient City" id="patientaddress-city" class="form-control ng-untouched ng-pristine ng-invalid" required="" maxlength="65"></div><label class="vsp-form-group-label"
id="patientaddress-city-label" for="patientaddress-city"> Patient City </label><!----><vsp-validation-message id="patientaddress-city-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><ng-select role="listbox" aria-label="Patient State" name="state" bindvalue="value" id="patientaddress-state" class="ng-select ng-select-single ng-select-searchable ng-select-clearable ng-untouched ng-pristine ng-invalid"
required="">
<div class="ng-select-container">
<div class="ng-value-container">
<div class="ng-placeholder">Patient State</div><!----><!---->
<div class="ng-input"><input role="combobox" type="text" autocorrect="off" autocapitalize="off" autocomplete="off" id="patientaddress-state-ng-select-filter-input" aria-expanded="false"></div>
</div><!----><!----><span class="ng-arrow-wrapper"><span class="ng-arrow"></span></span>
</div><!---->
</ng-select></div><label class="vsp-form-group-label" id="patientaddress-state-label" for="patientaddress-state-ng-select-filter-input"> Patient State </label><!----><vsp-validation-message id="patientaddress-state-validation"
class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group class="col-md-4">
<div class="form-group vsp-form-group form-group-animation-empty">
<div><input name="zip" vspvalidatezip="" placeholder="Patient Zip Code" id="patientaddress-zip-code" maxlength="5" class="form-control ng-untouched ng-pristine ng-invalid" required=""></div><label class="vsp-form-group-label"
id="patientaddress-zip-code-label" for="patientaddress-zip-code"> Patient Zip Code </label><!----><vsp-validation-message id="patientaddress-zip-code-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group></div>
</vsp-address>
<div class="row">
<div class="col-md-12"><vsp-radio-button-group ngmodelgroup="authorizedRepresentative" messages="Authorized Representative status is required." class="ng-untouched ng-pristine ng-invalid">
<div class="radio-button-group radio-button-group-inline">
<div class="radio-button-group-contents"><label class="radio-button-group-label ng-star-inserted">Are you an <a href="https://cdn.vsp.com/dam/jcr:72bfe9e6-6d66-4e1a-b5a5-6083b5de17ef">authorized representative</a> for this
patient?</label><!---->
<div class="radio-button-group-content d-flex justify-content-start"><vsp-radio-button-wrapper label="Yes">
<div class="form-check form-check-radio"><input required="" type="radio" name="authorizedRepresentativeValue" id="radio-is-authorized-representative-yes" class="ng-untouched ng-pristine form-check-input ng-invalid"><label
class="form-check-label" for="radio-is-authorized-representative-yes">Yes</label></div>
</vsp-radio-button-wrapper><vsp-radio-button-wrapper label="No">
<div class="form-check form-check-radio"><input required="" type="radio" name="authorizedRepresentativeValue" id="radio-is-authorized-representative-no" class="ng-untouched ng-pristine form-check-input ng-invalid"><label
class="form-check-label" for="radio-is-authorized-representative-no">No</label></div>
</vsp-radio-button-wrapper><!----></div>
</div><!---->
</div>
</vsp-radio-button-group></div>
</div>
<div class="row"><vsp-form-group label="Sender First Name" class="col-md-4">
<div class="form-group vsp-form-group disabled form-group-animation-empty">
<div><input id="sender-first-name" name="senderFirstName" minlength="1" maxlength="65" required="" vspvalidatestandardtext="" placeholder="Sender First Name" class="form-control ng-untouched ng-pristine" disabled=""></div><label
class="vsp-form-group-label" id="sender-first-name-label" for="sender-first-name"> Sender First Name </label><!----><vsp-validation-message id="sender-first-name-validation"
class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><vsp-form-group label="Sender Last Name" class="col-md-4">
<div class="form-group vsp-form-group disabled form-group-animation-empty">
<div><input id="sender-last-name" name="senderLastName" minlength="1" maxlength="65" required="" vspvalidatestandardtext="" placeholder="Sender Last Name" class="form-control ng-untouched ng-pristine" disabled=""></div><label
class="vsp-form-group-label" id="sender-last-name-label" for="sender-last-name"> Sender Last Name </label><!----><vsp-validation-message id="sender-last-name-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group><!----></div>
</fieldset><!---->
</vsp-contact-us-patient-info></div>
<div class="vsp-form">
<fieldset>
<legend class="form-section-header">Comments</legend><vsp-contact-us-comments name="comments" required="" class="ng-untouched ng-dirty ng-invalid"><vsp-form-group>
<div class="form-group vsp-form-group form-group-animation-empty">
<div><textarea name="comments" vspautoresize="" rows="8" class="form-control form-control-text-area ng-untouched ng-pristine ng-invalid" id="comment-input" placeholder="Enter comment here..." maxlength="2000" required=""
style="height: 185px;"></textarea><vsp-tool-tip aria-label="comments tooltip button" class="comments-tooltip ng-star-inserted">
<div form-group-icon="">
<!----><i role="button" container="body" class="icon-tooltip d-none d-md-block" tabindex="0" aria-label="Comments may only include the following: alphanumeric characters, upper and lower case, period, comma, question mark, colon, semicolon, dash, exclamation, dollar sign, single quote, at symbol, hash, percent, ampersand and parentheses."></i><!----><i role="button" triggers="click:blur" container="body" class="icon-tooltip d-md-none" tabindex="0" aria-label="Comments may only include the following: alphanumeric characters, upper and lower case, period, comma, question mark, colon, semicolon, dash, exclamation, dollar sign, single quote, at symbol, hash, percent, ampersand and parentheses."></i><!---->
</div>
</vsp-tool-tip><!----></div><label class="vsp-form-group-label" id="comment-input-label" for="comment-input"> Enter comment here... </label><!---->
<div form-group-before-validation-text="" class="remaining-text">Remaining: 2000 Characters</div><vsp-validation-message id="comment-input-validation" class="ng-star-inserted"><!----></vsp-validation-message><!---->
</div>
</vsp-form-group></vsp-contact-us-comments>
</fieldset>
</div><vsp-re-captcha class="ng-star-inserted">
<div id="recaptcha" data-callback="handleReCaptchaSubmit" data-size="invisible" class="g-recaptcha" data-sitekey="6Ldgje4aAAAAAFj7m3Yo68-WqbGpug1i728iHeak">
<div class="grecaptcha-badge" data-style="bottomright"
style="width: 256px; height: 60px; display: block; transition: right 0.3s ease 0s; position: fixed; bottom: 14px; right: -186px; box-shadow: gray 0px 0px 5px; border-radius: 2px; overflow: hidden;">
<div class="grecaptcha-logo"><iframe title="reCAPTCHA" width="256" height="60" role="presentation" name="a-sixs7d8o0w78" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6Ldgje4aAAAAAFj7m3Yo68-WqbGpug1i728iHeak&co=aHR0cHM6Ly93d3cudnNwLmNvbTo0NDM.&hl=de&v=pxZcVU8Dk73FyvFvdCgp2MSG&size=invisible&cb=tqwdb56d4mlj"></iframe></div>
<div class="grecaptcha-error"></div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
</vsp-re-captcha><!---->
<div class="d-flex justify-content-end mt-40"><button type="submit" vspvalidationmessagetrigger="" class="btn btn-primary btn-extra-padding button-loader">Submit</button></div>
</form>Text Content
* Members * Members Log In / Create an Account Choose Language Know someone who has lost or broken their eyewear due to a recent natural disaster? VSP can help—visit disaster.vsp.com Know someone who has lost or broken their eyewear due to a recent natural disaster? VSP can help—visit disaster.vsp.com * * * Search * FIND A DOCTOR * BENEFITS * OFFERS * EYEWEAR AND WELLNESS * PLAN OPTIONS * SHOP CONTACT US Whether you have questions about your vision benefits, would like to purchase vision benefits or find an eye doctor, we can help. Quick Links FAQs Call Us Email Member Services File a Grievance CONTACT US Whether you have questions about your vision benefits, would like to purchase vision benefits or find an eye doctor, we can help. Quick Links FAQs Call Us Email Member Services File a Grievance CONTACT US Whether you have questions about your vision benefits, would like to purchase vision benefits or find an eye doctor, we can help. Quick Links FAQs Call Us Email Member Services File a Grievance EMAIL MEMBER SERVICES Reach out to us and we’ll get back to you within 24-48 hours. What can we help you with? What can we help you with? What can we help you with? Primary Member Information First Name Last Name Email Confirm Email DOB Last 4 of SSN OR Member ID Patient Information Same as primary member Patient First Name Patient Last Name Patient Address Patient City Patient State Patient State Patient Zip Code Are you an authorized representative for this patient? Yes No Sender First Name Sender Last Name Comments Enter comment here... Remaining: 2000 Characters Submit -------------------------------------------------------------------------------- CONTACT * Contact Us * Call Member Services * Email Member Services * GRIEVANCE FORM * FAQs LEGAL AND PRIVACY * Legal * Non-Discrimination Statement * * * Notice of Privacy Practices * Patient Rights * Terms and Conditions * Accessibility * Natural Disaster Resources * Privacy Statement RELATED SITES * VSP Individual Plans * VSP Vision * Eyeconic * Provider Hub * Eyes of Hope * Global Access Plan ABOUT * About This Site * About VSP * Become a VSP Provider * Careers * Shop * Sitemap CONNECT * Facebook * Twitter * Instagram * Pinterest * YouTube LANGUAGE ASSISTANCE Español| 繁體中文| Tiếng Việt| Tagalog| 한국어| русский| العربية| Kreyòl Ayisyen| Français| Deutsch| Polski| Português| Italiano| 日本語| فارسی| Հայերեն| Hmoob| ਪੰਜਾਬੀ| हिंदी| ภาษาไทย| ខ្មែរ| ພາສາລາວ| Srpsko-hrvatski| বাংলা| Shqipe| ܣܘܼܪܸܬ݂ © 2023 Vision Service Plan. All rights reserved. © 2023 Vision Service Plan. All rights reserved.