Prior Authorization Cover Sheet Date:

Prior Authorization Cover Sheet
Attachment B
Date:
To:
Call Center
Fax:
408-885-7544
From:
Santa Clara Family Health Plan
Fax:
Phone:
408-874-1957
408-874-1821
PAR Receipt Date:
Priority Status:
Member Name:
Home Number:
Phone Number 2:
Language:
Message:
Member is in need of mental health services. Members with ID numbers beginning with “7” are Healthy Kids.
ID numbers beginning with “8” are Healthy Families. ID numbers beginning with “2” are Healthy Workers.
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210 E. Hacienda Ave ● Campbell, CA 95008 ● www.scfhp.com
Santa Clara Family Health Plan
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