1. No category

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.
*** CONFIDENTIALITY NOTICE ***
These documents accompanying this facsimile transmission contain confidential information belonging to the sender,
which is legally privileged. This information is intended only for the use of the individual or entity named above. The
authorized recipient of this information is prohibited from disclosing this information to any other party and is required to
destroy the information after its stated need has been fulfilled. If you are not the intended recipient, you are hereby
notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is
strictly prohibited. If you have received this facsimile in error, please notify the sender immediately to arrange for a
return of these documents.
210 E. Hacienda Ave ● Campbell, CA 95008 ● www.scfhp.com
Santa Clara Family Health Plan
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