Forms and Resources
The Forms and Resources page is designed to make it easier for VHP members to file a claim, appeal a denial of benefits, and learn more about their coverage. If you do not find what you need on this page, you may contact VHP's Member Services Department at 1.888.421.8444.
The Member Forms section provides information and links to forms that VHP Members might need to use to help us give you the best care.
The Authorization of Use and/or Disclosure of Protected Health Information form is used to grant permission to a person(s) you designate to view your medical records, such as your doctor, health care provider, or lawyer. When you complete and sign this form, health information about you will be released as you have indicated on the form.
Please return the completed form to Attn: Member Services, Valley Health Plan, 2480 N. First Street Suite 160, San Jose, CA 95131, or fax it to 1-408-885-4425.
Authorization for Use and/or Disclosure of Protected Health Information Form
The Authorized Representative Form (AOR) is used by members who want to select a person to communicate with Valley Health Plan (VHP) on their behalf about appeals and grievances. When you choose a personal representative, that person can make decisions for you in most healthcare matters and can use, receive, and disclose your Protected Health Information (PHI).
The Coordination of Benefits and Information Form is required to be filled out if you or your dependent(s) have, or are entitled to other group health insurance, including Medicare. It is required by California law that you provide VHP with information about any other health insurance coverage that you care for yourself and/or your dependents.
A dependent child who is incapable of self-support due to a continuously disabling illness or injury may be continued as a family member on the parent’s Valley Health Plan contract. Physically or mentally handicapped Eligible Dependent(s) who is incapable of sustaining employment and is dependent upon you for support and maintenance may continue Coverage if the child was handicapped on the day before reaching age 26. The child can be covered under the Plan through age 25 or until the child recovers from the handicap or the date the child is no longer chiefly dependent on you for support and maintenance.
We encourage our Members to contact us first to resolve any concerns about your care or benefits. However, Members wishing to file a Grievance about any aspect of the services provided by the Valley Health Plan (VHP) may do so by following the Grievance and Appeals process.
A Grievance can be filed on your behalf by a Member Services Advocate or you can complete a Grievance Form on your own and submit it to Valley Health Plan (VHP). Grievance forms are available in three languages through VHP, at your provider's office, and by using the links below
VHP Member Grievance and Appeal Form - English
VHP Member Grievance and Appeal Form - Spanish
VHP Member Grievance and Appeal Form - Vietnamese
VHP Member Grievance and Appeal Form - Chinese
VHP Member Grievance and Appeal Form - English Fillable Form
VHP Member Grievance and Appeal Form - Spanish Fillable Form
VHP Member Grievance and Appeal Form - Vietnamese Fillable Form
VHP Member Grievance and Appeal Form - Chinese Fillable Form
The Medical Claim Reimbursement Form includes information needed to review a Member's reimbursement request, preventing delays in the review process. It also acts as a Release of Information form which includes a signature in the case a member has not submitted any medical record(s) needed to complete the review.
Members can file a Medical Claim Reimbursement Form within ninety (90) days of the date of service if you received claims or bills from a provider for services with a balance due and/or to request reimbursement for services received that were not able to be billed to VHP and had to be paid out of pocket such as:
- Urgent Care & Emergency Services when out of the Valley Health Plan (VHP) network
- Prescription Drugs for the above stated or when in-network and VHP network pharmacies are closed
Medical Claim Reimbursement Form
Formulario de Reembolso por un Reclamo Medico
The Pharmacy Reimbursement Form includes information needed to review a Member's reimbursement request for covered prescriptions and medications that the Member had to pay for out-of-pocket at a pharmacy in the United States for the following reasons:
- You did not have your ID card at the time of purchase
- You were charged for medication received during an Urgent/Emergent Visit
- You were administered a Medicare Part D covered vaccine at your doctor’s office
- Primary coverage is with another insurance carrier. (Coordination of Benefits)
Prescription Reimbursement Form
The Foreign Prescription Reimbursement Form includes information needed to review a Member's reimbursement request for covered prescriptions and medications that the Member had to purchase outside of the United States. Reimbursement will be made to the Cardholder unless otherwise stated. Be sure the address you provide is a secure location to mail the check. VHP and Navitus are not responsible for lost or stolen checks.
VHP Members choosing to participate in any of our fitness classes offered by the Health Education Department, both in-person and online, must fill out the Release and Waiver of Liability for Fitness Classes before they can participate.
Find out the classes currently are being offered, times, and locations on the VHP Health Education page.
The Plan Information section is where you will find information to help you get the most out of your health coverage plan.
An Advance Health Care Directive is a formal document, signed by you in advance of a severe illness or injury, which will guide your physician(s) when providing treatment. Notwithstanding this document, you still have the right to make medical and other health care decisions for yourself so long as you can give informed consent regarding the particular decision. As long as you can speak for yourself, Plan Providers will honor your wishes. But, if you become so incapacitated that you cannot make an informed decision, this directive will guide your health care treatment based on the directions you set out in the Advance Health Care Directive.
Valley Health Plan affirms That:
- Utilization Management decision making is based only on appropriateness of care and service and existence of coverage.
- The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.
- There are no financial incentives for Utilization Management decision-makers.
VHP offers a no cost, innovative Autism Care Management Program designed to support families taking care of a child with Autism Spectrum Disorder (ASD). Program care managers work with parents to deliver one-on-one support, prioritize care issues, and address any barriers that are obstacles to the family or their child receiving necessary health care services.
The VHP care manager serves as the primary point of contact for families and can answer questions or address any problems the family is experiencing in making sure their child’s health care needs are met. VHP’s care managers are ASD specialists with the experience and understanding to help families living with a developmental disorder.
Through the Autism Care Management Program families develop a relationship with their care manager that allows them to function as an extension of their health care team. This relationship helps to ensure that families get coordinated support in alignment with the family’s other doctors and specialists.
Families with a child with an ASD diagnosis are contacted by one of our care managers after becoming a VHP member or when a current member receives an ASD diagnosis. If you are interested in finding out more about VHP’s Autism Spectrum Disorder Care Management Program, please call 1.888.863.7586 (toll-free)
Is Your Information Up-to-Date?
It is very important that VHP has your correct address and phone number on file. We want to make sure you receive our important mailings about additions or changes to benefits, providers/networks, or tools to help you maintain your overall health.
If your information has changed, please call the number that applies to your coverage:
Employer Group Plan Members
Your Human Resources Department
Covered California Plan Members
Covered California Service Center
Individual & Family Plan Members
Valley Health Plan Member Services
1.888.421.8444 (toll-free), choose Option 3
Choosing and Changing your Primary Care Provider (PCP)
Valley Health Plan (VHP) offers you several ways to choose a Primary Care Provider (PCP). We encourage you to take the time to research available Primary Care Provider and make an informed choice based upon you and your family’s needs and preferences.
Ways to make an informed decision:
- Visit the VHP Provider Search to learn more about VHP’s network of doctors and which doctors are available to you within your plan.
- Contact Member Services at 1.888.421.8444 (toll-free) to speak with one of our knowledgeable and friendly Member Service Specialists.
- Use the internet to research physicians that you find in the VHP Provider Search to read about their credentials, affiliations, and specialties. You can also use the internet to find out what other patients say about the care they receive from a physician.
- Talk to your friends, family, and neighbors. Often the best information comes from the people you know and trust.
As a Member, you have the right to change your Primary Care Provider (PCP) at any time. The change will take effect on the first day of the next month after your request is received. During that time a new Member ID card will be sent to you with the name of your new PCP.
It is important that you wait to seek services from your new PCP until the change has become effective or you could be financially responsible for any services received.
To choose or change your PCP, contact VHP Member Services by email at [email protected], by phone at 1.888.421.8444 (toll-free), or by using the Contact Us form.
If you or your Dependent(s) have an Acute Condition, a Serious Chronic Condition, a Pregnancy, a terminal illness, or your newborn child between birth and age 36 months is under medical care, you may be eligible to continue to receive treatment from your provider (e.g. physician or hospital):
if your treating Plan Provider terminates as a VHP Plan Provider, or
if you are receiving care from a non-participating provider at the time of your enrollment in VHP Plan.
You have the right to request a copy of the Plan’s continuity of care policy. To request a copy of this policy, call Member Services at 1.888.421.8444 (toll-free).
To choose or change your PCP, contact VHP Member Services at [email protected] or by phone at 1.888.421.8444 (toll-free).
For more information visit the VHP Continuity of Care page.
Everyone is concerned about rising health care costs and many assume there’s nothing they can do about it. However, estimates are that up to 3 percent of health care costs are wasted by overstated, double-billed, or otherwise fraudulent charges. We all pay for these excesses. Valley Health Plan (VHP) is committed to the prevention, detection and reporting of health care fraud, waste and abuse. You, our health plan members, are a vital part of helping us address this problem. In the process, you are protecting yourself from unnecessary higher costs and potentially more serious concerns, such as identity theft.
We encourage members to notify VHP of any suspicious activity you might encounter while receiving care from one of our practitioners or providers. All complaints regarding fraud will be investigated. This will allow VHP to take the necessary actions to protect members from unlawful activities.
For more information about how to spot and report suspicious activity visit the Fraud, Waste, and Abuse page.
Your benefit plan requires members to obtain all covered services through Plan Providers in the VHP Network, except in the case of an Emergency Room or out-of-area Urgent Care visit. If you seek services from Non-Plan Providers without a VHP approved referral, you may be financially responsible for the charges.
To find a Plan Provider – use our Provider Search or contact VHP Member Services for assistance at:
Monday - Friday
We understand that health coverage can be intimidating. Sometimes you read about your benefits and it seems like they are written in a foreign language. The VHP Glossary of Health Coverage and Medical Terms can help you understand common health coverage terms, so you can get the most out of your plan.
Download a PDF copy of the VHP Glossary of Health Coverage and Medical Terms
As a Member, you are entitled to certain rights and services. You also have a responsibility to participate in your health care. A good partnership between you and your PCP will enhance our ability to provide appropriate services and for you to get the most from your coverage plan.
Visit the VHP Member Rights and Responsibilities page for a complete list of your rights and responsibilities.
Valley Health Plan (VHP) contracts with Primary Care Physicians (PCPs) and Plan Providers who are responsible to provide and coordinate Covered Services or Benefits for you, the Member. Except in the case of Emergency Services, Urgently Needed Services, or if VHP has Prior Authorized services, you must receive all of your care from these VHP Plan Providers. If you receive services outside of the VHP Network without Prior Authorization, you may be responsible for the charges
The Utilization Management (UM) Department ensures appropriate use of resources by evaluating and determining coverage for medical care services for members and providers.
To receive information about the UM process or the status of authorizations and referrals, call Member Services at 1.888.421.8444 (toll-free), Monday through Friday, 9:00 a.m. – 5:00 p.m. PST.
Language services are available at any time, for the hearing and speech impaired, call the California Relay Service (CSR) by simply dialing 711 or the 800 CRS number of your modality. All calls received after business hours, on weekends, and on holidays will be returned on the next business day.
The California Department of Managed Health Care (DMHC) requires health plan members to be seen in a timely manner. The primary intent of these regulations and the underlying legislation is to ensure that the VHP network of providers has the capacity and availability to provide care to you within certain timeframes for the various levels of care. However, sometimes waiting longer for care is not a problem. Your physician may give you a longer wait time if it would not be harmful or your health. It must be noted in your record that a longer wait time will not be harmful to your health.
Please take time to read the following California Timely Access Standards on the VHP Timely Access page.
Employer Group Plan Information
The Employer Group Plan Information section is where you will find specifics about our Classic and Preferred Plans.
Valley Health Plan's Benefits and Coverage Handbook, also known as the Combined Evidence of Coverage or EOC, for Employer Group Plan Members provides an explanation of your rights, benefits, services, and responsibilities. It also explains Valley Health Plan's health maintenance organization responsibilities to you.
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit us at www.valleyhealthplan.org or call 1-888-421-8444. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-888- 421-8444.
Summary of Benefits and Coverage (SBC) for Classic and Preferred Plans
The Schedule of Benefits and Coverage Matrix (SOBM) can be used to help you compare coverage benefits and is a summary only. The Evidence of Coverage (EOC) and Plan contract should be consulted for a detailed description of coverage benefits and limitations.
Schedule of Benefits and Coverage Matrix (SOBM) - CY22
Members of VHP's Classic or Preferred Plan can fill out a VHP temporary ID card if you are in need of services or a prescription and have either lost or not yet received your permanent VHP ID Card. If you are a member of the PMGSJ Network or SCCIPA Network, please be sure to use your Network-specific ID Card. All other Classic or Preferred Plan Members should use the VHP Employer Group Temporary ID Card
VHP Employer Group Temporary ID Card
VHP Employer Group PMGSJ Network ID Card
Covered California and IFP Information
The Covered California and Individual & Family Plan Information (IFP) section is where you will find specifics about our Covered California and IFP Plans.
Valley Health Plan's Benefits and Coverage Handbook, also known as the Combined Evidence of Coverage or EOC, for Covered California and IFP Members provides an explanation of your rights, benefits, services, and responsibilities. It also explains Valley Health Plan's health maintenance organization responsibilities to you.
Benefits and Coverage Handbook
The Summary of Benefits and Coverage (SBC) can help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit us at valleyhealthplan.org or call 1-888-421-8444. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-888- 421-8444.
The Schedule of Benefits and Coverage Matrix (SOBM) may be used to help you compare coverage benefits and is a summary only. The Evidence of Coverage (EOC) and Plan contract should be consulted for a detailed description of coverage benefits and limitations.
To view all of the Covered California and IFP SBCs and SOBMs visit the page linked here.Covered California and IFP Summaries of Benefits and Coverage (SBC) and Schedules of Benefits and Coverage Matrixes (SOBM)
Members of VHP's Covered California or IFP Plans can fill out a VHP temporary ID card if you are in need of services or a prescription and have either lost or not yet received your permanent VHP ID Card. If you are a member of the PMGSJ Network, please be sure to use your Plan and Network-specific ID Card. All other Covered California Plan Members should use the VHP Covered California Temporary ID Card and all other IFP Plan Members should use the VHP Individual & Family Plan Temporary ID Card
VHP Covered California Temporary ID Card
VHP Covered California PMGSJ Network Temporary ID Card
VHP Covered California SCCIPA Network Temporary ID Card
VHP Individual & Family Plan Temporary ID Card
VHP Individual & Family Plan PMGSJ Network Temporary ID Card
VHP Individual & Family Plan SCCIPA Network Temporary ID Card
The Additional Resources section is where you will find information about things like immunization schedules or how to request electronic medical records.
Better Health, Better You
One of the best ways to take an active role in managing your health and the health of your family is to see your doctor at least once a year and get your annual preventive healthcare screenings.
Why is prevention important?
Prevention is a vital part of staying healthy. Keeping up to date on your preventive care can help catch potential health problems before they become serious. Annual preventive visits are no-cost visits. Here is some important health information that you can discuss with your doctor.
Vaccines help prevent the spread of illness and reduce severity of illness if you do get sick. Children need routine childhood vaccines on a specific vaccine schedule; talk to your doctor to make sure your child’s vaccines are up to date. Adults also need vaccines to prevent illnesses like the flu and serious complications from COVID.
On August 31, 2022, The Food and Drug Administration (FDA) authorized the use of the updated “bivalent” booster targeting the omicron BA.5 variant. The Center for Disease Control and Prevention (CDC) recommends everyone eligible to stay up-to-date with the COVID-19 vaccines, including boosters.
Have the right screening tests
Health screenings help you and your doctor detect, manage, and even prevent some health-related problems. Men and women should be seen once a year to look at thinks like blood pressure, blood sugar, and if you need other screening tests like a colonoscopy (test to detect colon cancer), Pap smear (to detect cervical cancer), or a mammogram (test to detect breast cancer).
The American Cancer Society recommends starting regular screening for colon cancer starting at the age of 45.
High blood pressure can lead to many serious health problems. It is important to have your blood pressure checked at least once a year. At your annual wellness visit, your doctor will check your blood pressure to determine if it is high or normal.
Blood Sugar Test
High blood sugar levels may be a sign of diabetes. The US Preventive Services Task Force (USPSTF) recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who are overweight or obese.
People who have diabetes or high blood sugar can develop problems with vision, sensation (feeling things on your skin), and kidney problems. If you have diabetes, your doctor will recommend additional screening tests to check the health of your eyes, nerves (skin), and kidneys.
Your practitioner will explain your test results and help identify ways you can manage your health. Other screenings may be right for you based on your age and personal and family history. Talk to your doctor to see what is recommended for you.
There are simple nutritional tips to help stop and prevent diabetes, starting with making healthier choices and lifestyle changes. Sometimes, the right diet and lifestyle choices can even reverse type two diabetes.
VHP continuously works to improve your fitness, health, and wellness classes as a VHP Member. VHP offers nutrition classes and online and/or in-person fitness classes. To learn more, please register for VHP's free fitness classes or virtual classes.
If you have any questions about our free classes, please get in touch with VHP’s Health Education Department or call 408-885-3490.
Mental Health & Substance Use Screenings
Inform your doctor or primary care physician (PCP) if you have mental health and substance use concerns. Your doctor will screen for behavioral health issues just like they screen for medical issues. Your PCP can assess your needs and assist you in taking the initial steps toward treatment. Mental Health America also has free screening tools you may use in the privacy of your own home.
VHP has case managers who are here to support you in accessing care. Email VHP Case Management or call them at 408-885-2600. VHP offers a wide range of care management programs to our members. The programs consist of case management, care coordination, and preventive health education and are FREE for members who qualify based on their medical needs.
Did you know that VHP offers reliable 24/7 health care by phone or video to help you get better and stay well? VHP members can use MDLIVE to get care without leaving home. All VHP members can access certified providers, mental health, and substance use services for a wide range of urgent and non-emergency conditions.
Learn more about your MDLIVE benefit or call 1-888-467-4614 (toll free) to activate your account or schedule an appointment.
Immunizations, also known as vaccinations, help protect you and your children from getting an infectious disease. When you get yourself or your child vaccinated, you help protect others as well
Immunizations are important for a variety of reasons. By receiving an immunization for a disease, a person defends him or herself against catching that disease. But the benefits do not stop there; society gains a collective immunization as more and more people become immune to a particular disease.
CDC Immunization Schedule Recommendations or Information
Link to immunization schedule for infants and children (birth to 6 yrs)
Link to immunization schedule for children and adolescents (7 yrs to 18 yrs)
Link to immunization schedule for adults (19 yrs and older)
Versiones en Español
Enlace a Vacunas recomendadas para niños, desde el nacimiento hasta los 6 años de edad
Enlace a Vacunas recomendadas para los niños desde los 7 hasta los 18 años de edad
Enlace a una Serie de Informacion para Adultos Vacunas
Valley Health Plan offers Pediatric Dental Services through The Liberty Dental Plan of California Program (LDP). This provides essential pediatric dental care through a convenient network of Contract Dentists in the VHP service area. These Dentists are screened to ensure that our standards of quality, access, and safety are maintained. The network is composed of established dental professionals. When you visit your assigned Contract Dentist, you pay only the applicable Copayment for Benefits up to the Out-of-Pocket Maximum.
Link to find a Liberty Dental Dentist
You have a right to your health records. A federal law called the Health Insurance Portability and Accountability Act (HIPAA) gives you the right to see and get a copy of your health record. Most health insurance plans and— including doctor’s offices, clinics, hospitals, pharmacies, labs, and nursing homes — must follow this law.
Lucile Packard Children's Hospital Electronic Medical Records
Santa Clara Valley Medical Center (SCVMC) Medical Records
Stanford Health Care Medical Records
Sutter Health and Palo Alto Medical Foundation (PAMF) Electronic Medical Records
The VHP Quality & Strategic Improvement mission is to support the well-being of our members through a commitment to accessible, high-quality, equitable health services and community-focused, local care. Our focus is to improve every aspect of quality within the Valley Health Plan delivery system. Our team monitors and evaluates the activities in hospitals, primary care offices, and anywhere our members receive care. In addition, we also improve, create, and provide quality services and systems internally at Valley Health Plan.
To make a Third-Party Liability (TPL) Inquiry, follow the process below:
- Billing/Lien/Subpoena Records Requests - mail to: Valley Health Plan 2480 N. First St, Ste 160, San Jose, CA 95131 along with a copy of the HIPAA signed authorization (addressed to Valley Health Plan) and a $15.00 check payable to Valley Health Plan.
- Inquiries: To follow up on your request, please fax a copy to 1.408.885.5926 or call 1.408.885-5931.
- Questions: Please email to [email protected].