Forms - Vision Plan of America

Please select the form you need from the list below.

To submit forms directly to us online please click on the
To download forms in Adobe Acrobat format please click on the

For Providers / Providers Search
Provider Utilization Report
Schedule of Extras (For All Plans Except M-PLUS & MQ-2)
Plan M-Plus (Description of Benefits & Co-Payments)
Vision Provider Directory Dental Provider Directory
For Individual Plan Enrollment
VIP Premier	M-Plus	Best Choice	Emerald
For Members
Grievance Use this form if you wish to report a complaint with Vision Plan of America regarding your membership.
Grievance Form (Spanish)/Proceso de Queja Use esta forma si necesita hacer una queja con Vision Plan of America sobre su plan de vision.
Status Change Form Use this form if you wish to make changes to your membership. (Example: Change of Name/Address, Change of Provider, Add/Delete Dependents, etc.)
Status Change Form (Spanish)/Cambio de Estado Use esta forma si necesita hacer cambios a su membresía. (Por Ejemplo: Cambio de Nombre/Domicilio, Cambio de Proveedor, Agregar/Cancelar Dependientes, etc.)
For Brokers/Agents
Agent Service Agreement Please print and fax/mail to VPA along with a copy of your license.
Request for Supplies If you require additional VPA supplies and materials.
Request for Proposal Receive a custom proposal for your company's needs.
For Groups/Group Administrators
Please Note: Only Group Administrators are allowed to enroll employees online. If you are an Employee please notify your Employer before enrolling.
Vision Plans General HMO Employee Enrollment Form for Groups with Plans A, B, or C. HMO Employee Enrollment Form HMO Employee Enrollment Form (Spanish)
Vision & Dental Plans General HMO Employee Enrollment Form for Groups with Vision & Dental Plans. HMO Employee Enrollment Form V&D HMO Employee Enrollment Form V&D (Spanish)
Status Change Form Use this form if you wish to make changes to your membership. (Example: Change of Name/Address, Change of Provider, Add/Delete Dependents, etc.)