Vsp Video Display Terminal Confirmation Form
VSP VIDEO DISPLAY TERMINAL CONFIRMATION FORM
For your protection, California law requires the following to appear on this form: Any person who knowingly presents a
false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in prison.
The VSP Video Display Terminal (VDT) Confirmation Form is only provided to CSU employees who meet the
necessary job requirements as determined by the CSU campus benefits office. This form must be completed
by the employee and provided to a VSP Select Network doctor to receive the supplemental VDT benefit.
Please call VSP Member Services at 800-877-7195 if you have questions about the benefit.
INSURED TO COMPLETE AND SIGN THIS SECTION
Employee’s Name (Last Name First)
Gender
Last 4 Digits Of Social Security
Male Female
Number
Street Address
Employee’s Birthdate
City, State, and Zip Code
General Visual Information
1. Time spent at VDT? _____________ Hours per day.
2. Work is performed while: Sitting Other (please describe):
3. Job Title: ___________________________________________________________________________________________________________
4. Lighting in work area (Please describe):________________________________________________________________________________
Are you experiencing any of the following symptoms while at your VDT? Check all which apply.
Headaches Blurred Near Vision Blurred Distant Vision Slowness in Focusing (Distant to near and back)
Double Vision Sore or Tired Eyes (Strain) Glare (Light) Sensitivity Dry or Watery Eyes Burning, Itching or Red Eyes
Neck and Shoulder Pain Back Pain
Do you wear glasses while working at the VDT? YES NO Please bring them with you to the examination
Do you wear contacts while working at the VDT? YES NO Please bring them with you to the examination
Do you view reference material while working at the VDT? YES NO What percentage of time? _____________________
In order for the doctor to accurately assess your occupational vision needs and possible appropriate eye wear, the following
distances/direction must be completed:
Viewing distance eye to VDT screen is ______ inches. Viewing distance eye to VDT keyboard is ______ inches.
Viewing distance eye to reference material is ______ inches.
The center of the VDT screen is: above equal to below eye level If above or below, by how many inches? ______
Reference material is: above equal to below eye level If above or below, by how many inches? ______
The above answers are true and complete according to the best of my knowledge and belief. By signing this form, I hereby
certify that my CSU job requires me to use a video display terminal four or more hours per day on a regular, ongoing basis. I
understand that if I obtain services and do not meet these VDT eligibility requirements, I will be responsible for any and all
charges incurred. I hereby assign payable benefits to participating providers.
_____________________________________________________________________________________________ ________________________
Employee Signature Date
OUT OF NETWORK INSTRUCTIONS:
Dollar for dollar you get the best value from your benefit when using a VSP Select Network doctor. If you decide to use a non-VSP Provider, the $10 exam copay
still applies. You’ll also receive a lesser benefit and typically pay more out-of-pocket. You are also required to pay the provider in full at the time of your appointment
and submit to the mailing address below both a copy of the this form and itemized receipt to VSP for partial reimbursement based on the plan allowances.
VSP
PO Box 997105
Sacramento, CA 95899-7105
Attn: Out-of-Network Claims
Group Number 12292796 10/2006
