Adult Annual Checkup Form ENG

Value Added Service | Adult Annual Checkup

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

Cook Children’s Health Plan cares about your health. We want to make sure our members get their annual checkups with their primary care provider for developmental well-being.

You can be eligible for one of these rewards:
One $25 gift card for STAR Members age 18 to 25 who complete an annual checkup OR
One $25 gift card for STAR Kids Members age 18 to 20 who complete an annual checkup

*Date of service must be within the current state fiscal year (September 1, 2026 - August 31, 2027)

Cook Children’s Health Plan will check to see that the visit took place.
Member name:
By filling out this form, you attest that the person above has completed their annual well checkup visit
Member ID number:
Member DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Provider name:
Date of visit:

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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