Below are authorization forms for VHP providers.
Click on each (+)sign below.
Authorization Request (TAR)
Please clearly identify the service requested and the medical justification.
The following information is required:
- Diagnosis (ICD-10)
- Service Request (CPT-4)
- Number of visits requested
- Reason the service is medically necessary, including documentation (such as H&P and progress notes)
- Name of rendering provider requested
- Name of referral provider submitting the request
- Name of Member and Member's VHP ID number
If the Authorization Request Form (TAR) is not fully completed, the UM staff will request the needed information. If the additional information is not provided within 10 working days, the request will be closed. If the request has been closed, a new Authorization Request Form must be submitted to UM prior to performing services.
Please fax completed Authorization Request Form (TAR) to 408.885.4875.
Post Stabilization Telephone Number
VHP requires prior authorization for all post stabilization care. Effective immediately, please be advised that the number to call 24hrs per day/7 days per week is 1.855.254.8264.
Any call to any phone number other than 1.855.254.8264 does not constitute notice of patient admission or request for post stabilization care.
A fax about a patient admission or request for transfer does not constitute notice of this request either. This request must come via phone call to 1.855.254.8264.
If you have any questions or need additional help please contact Provider Relations at 408.885.2221
or our use our online Contact Us Form