COVID 19 Vaccine Form ENG

Value Added Service | COVID 19 Vaccine

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

You can receive a $10 gift card for members ages 6 months and up when you receive a COVID 19 vaccine or booster shot.
*Date of service must be within the current state fiscal year (September 1, 2026 - August 31, 2027)
Member first name:
Member last name:
Member ID number:
Member DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Parent phone number
Please enter a valid phone number.Format: (000) 000-0000.
Provider Name (last, first):
Vaccine or booster date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
You must submit proof of vaccination.
File Upload

Cancelof
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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