Alcohol or Drug Abuse Treatment Form ENG

Value Added Service | Alcohol or Drug Abuse Treatment

*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 gift card. To qualify for this reward you must:
• Be 13 years of age and older.
• Have a diagnosis of Alcohol or Drug Abuse (AOD) or dependency.
• Have received treatment within 14 days of diagnosis through one of the following:
1. An inpatient AOD admission
2. Outpatient visits
3. Intensive outpatient encounter or
4. Partial hospitalization
*Date of service must be within the current state fiscal year (September 1, 2026 - August 31, 2027)

We will require proof of your diagnosis date; you can submit your After Visit Summary.
Member name:
Member ID number:
Member DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Provider Name (last, first):
Date of diagnosis:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Treatment provider:
Treatment location:
Type of treatment:
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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