How to file a medical claim reimbursement form
- Forms must be submitted to Valley Health Plan within ninety (90) days of the date of service.
- 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.
- Original receipt(s) including:
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.