Flu Shot Form ENG

Value Added Service | Flu Shot

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

You can receive a $25 gift card when receiving a flu shot for members age 6 months of older.

*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
Phone number:
Please enter a valid phone number.Format: (000) 000-0000.
Provider name (last, first):
Flu shot date:

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