INSTRUCTIONS

    • Member Information
    • Gym/Health Club Information
    • Payment Information
    • Proof of Payment (Choose one from below)
      • Upload your proof of payment at the bottom of the form. If you choose to upload your purchase of proof, please upload one proof for each month you request.
      • Fax to (909) 397-0210. Please include a hard copy of the completed form, which will be emailed to you after you submit the form.
      • Mail your proof of payment to the address below. Please include a hard copy of the completed form, which will be emailed to you after you submit the form.
Inter Valley Health Plan
Claims Department/Gym
PO Box 6002, Pomona, CA 91769-6002
Member Care Team: (800) 251-8191
Hearing Impaired: TTY 711
Hours: Mon.-Fri., 7:30 am - 8:00 pm
* All fields are required unless otherwise noted

STEP 1: MEMBER INFORMATION

Why do we ask?


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Why do we ask?









STEP 2: GYM/HEALTH CLUB INFORMATION



STEP 3: PAYMENT INFORMATION

Please indicate which one of the following forms of proof payment you will submit:


$ / mo. (max. /mo.)



STEP 4: PROOF OF PAYMENT

If you'd like to submit this form online, you will need to upload your proof of payment along with it. If you decide to fax/mail your proof of payment, you will need to attach a hard copy of the completed form, which will be emailed to you after you submit the form.

Please select one:
I will fax/mail my claim and proof of payment.

I'm ready to upload my proof of payment now.
By submitting this form, you agree to the terms of service.