Authorization Request Form
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1
2AUTHORIZATION REQUEST
Section 1:
Patient Information
Instructions: This form is required for
First Name: _____________________________
Last Name: ____________________________________
authorization of services. Please complete all
the unshaded sections on this form and fax to
the Utilization Management Department at
Date of Birth: ____________________________
Sex (check one):
☐ Female
Valley Health Plan.
☐ Male
Address: __________________________________________________________________________
Fax #:
408.885.4875
Phone #: 408.885.4647
Phone: ______________________________
VMC Medical Record #: _______________________
Section 2:
Health Plan ID#: ___________________________________________________________________
Location of Authorization
☐ Inpatient
☐ Outpatient
Diagnosis: ___________________________
ICD9 Code: _________________________________
☐ Other_______________________________
Request Type (Check One)
Requested Provider
☐ Emergency
☐ Routine
☐ Urgent
☐ Retro
Provider Name: _____________________________________________________________________
Location: _________________________________________________________________________
Program/Line of Business (Check One)
_________________________________________________________________________
☐
Employer Group Plan
☐
SCFHP Medi-Cal
Covered CA/Individual & Family
SCFHP HK
☐
☐
Phone: ______________________________
Fax: _______________________________________
Services and Provider Requested
Section
3:
Attach supporting documents such as progress notes, consultation notes, operative/radiological reports, and/or prescriptions to avoid delay in
processing request
Quantity
Length of
Specific Services Requested
CPT4
or
Need
HCPC
1.
Medical Justification for Request
2.
Medical Justification for Request
3.
Medical Justification for Request
4.
Medical Justification for Request
Section 4
Requesting Provider: _____________________________ MD Signature: ___________________________________ Date: __________________
NOTE TO ALL PROVIDERS: This authorization is valid only if the patient is eligible on the date of service. Please recheck eligibility prior to delivering
service (VHP Commericial patients: 408.885.4760 or 1.888.421.8444 – Medi-Cal Managed Care, Healthy Kids & Healthy Families patients: 1.800.260.2055).
VHP Provider Manual - Authorization Form
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