ADHD Assessment Intake Form

Value Added Service | ADHD

*Valid September 1, 2026 to August 31, 2027
Dear Cook Children’s Health Plan Member,

Cook Children’s Health Plan would like to send you a one time $50 reward, for:

• Members ages 6 to 12 years of age and newly diagnosed with Attention Deficit Hyperactivity Disorder.
• Newly diagnosed with ADHD and receiving medication for the first time.
• Filled a ADHD medication for the first time and
• After following up with a practitioner with prescribing authority within 30 days of receiving the medication.
• Members with an existing diagnosis of ADHD will become eligible for the VAS if they do not get medicine for 120
days.

*Date of service must be within the current state fiscal year (September 1, 2026 - August 31, 2027)
Member name:
Member ID number:
Member DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Name of Prescribing Practitioner:
Name of medication:
Date of diagnosis:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Date of follow-up appointment:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Please remember to register or log in to Healthmine to access your digital gift card and rewards.

Some limitations and restrictions may apply. Member must be active both on the date of service and on the date of request. If you have any questions please visit our website www.cookchp.org, contact us through the MyCookChildren’s Member Portal or call Member Services at 1-800-964-2247.
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