Provider Forms

• Valley Express Access Request Form- Online provider portal for referrals and Authorization Submissions. Valley express allows you to check eligibility, create referrals, create authorizations, search referrals, search authorizations, and submit clinical documentation with referrals and authorizations.
• Authorization Request Form - For Fax Authorizations, complete and submit this form to fax:408-885-4875.  Clearly identify the service requested and the medical justification for this service.                     
• Provider Dispute Form - If a VHP claim or authorization is denied, a provider may request reconsideration of denied services in writing. It will be acknowledged in writing to the provider within 15 business days and a resolution will be sent to the provider within 45 business days. This form can be mailed to: VHP Provider Relations Dispute Resolution P.O. Box 28387 San Jose, CA 95159. If you have any questions please call Provider Relations 408-885-2221 Option 2. 
• Provider Directory Online Verification and Change Form
  Online form for providers to verify their current information represented in the Provider Directory or submit changes electronically.
  
• Prescription Drug Prior Authorization Request Form
• Authorization for Use and or Disclosure of Protected Health Information
• Instructions for Claims and Tax Form Submission​
• 587 Tax Form
• 590 Tax Form
• W-9 F​orm
• ACH Enrollment Form​

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