How to File a Medical Claim Reimbursement Form

  1. Forms must be submitted to Valley Health Plan within ninety (90) days of the date of service.
  2. Fill out a Medical Claim Reimbursement Form and include:
  • ​Original receipt(s) including
    • ​Name of patient;
    • Name of doctor, hospital, 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.

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