Annual Dental Cleaning Form ENG

Value Added Service | Annual Dental Cleaning

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

Cook Children’s Health Plan will send you a one-time $10 gift card when you complete an annual dental cleaning. Members must be between the ages of 4 and 9 years to qualify.
*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
Provider Name (last, first):
Date of dental cleaning:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Proof of dental cleaning will be required. You may email proof to cchpcustomersvc@cookchildrens.org. Please include in your email the Member’s name and Member ID number. All information must be clear and complete.
File Upload

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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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