1.  Forms must be submitted to Valley Health Plan within ninety (90) days of the date of service.

2.  Fill out "Medical Claim Reimbursement Form" and include:

• Original receipt(s) including  
• Name of patient;
• Name of doctor, hospital, prescription/pharmacy, or other provider;
• Date paid; and
• Amount paid. 

• Original itemized bill(s) or invoice(s) from provider including: 
• Name of patient; 
• Date(s) of service; and 
• Nature of illness or injury - including medical and hospital billing code(s).

• Proof of payment
• Other proof of payment, such as a copy of a cashed check or credit card receipt may be required.

3.  Mail or walk-in the completed "Medical Claim Reimbursement Form" with receipts, bills, invoices, and medical records to:

Valley Health Plan
Attention: Member Services
2480 N. First Street, Suite 200
San Jose, CA 95131

*If in the event of a foreign receipt, payment will be calculated based on dollar conversion rate at the time of service.