Apply Now

Visit our portal page to begin your application today! It includes some easy to follow questions and the opportunity to submit your documents.

START APPLICATION

Forms

Smiling woman in a meeting with another person

We've made all the necessary forms available for download on our website. We encourage you to review the forms carefully and fill them out completely to ensure a smooth and hassle-free application process.

If you have any questions or need assistance with the forms, don't hesitate to contact us – we're here to help!

Initial Application

Supplemental

A screenshot of ACH Registration form — ACH Registration

A screenshot of CA Form 590 — CA Form 590

A screenshot of CA Form 587 — CA Form 587

Other

A screenshot of an Appeal form — Appeal Form

A screenshot of Notice of Privacy Policy — Notice of Privacy
Policy

A screenshot of a Patient Statement Form — PatientStatement
Form

A screenshot of Epinephrine Attestation Form — Epinephrine Attestation
Form

A screenshot of an Asthma Attestation Form — Asthma Attestation
Form

We're Here to Help You Every Step of the Way!

Don’t let some simple paperwork get in your way of getting money back. In person application assistance is available.

Reach out to us
Please call (408) 970-2001 to make an appointment. We are open Monday - Friday, 9:00am - 5:00pm.
Our office address is:
Santa Clara Valley Health
777 Turner Dr
San Jose, CA 95128

Learn More About MedAssist

Ready to learn more about how our money back program can benefit you? Dive deeper into the program by exploring our website and discovering all the ways we can help you earn cash back. Don't miss out on this opportunity to save money and protect your health.