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 "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 160
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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