HPV Vaccine Form ENG

Value Added Service | HPV Vaccine

*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 $25 gift card for members ages 9-13 years who obtain their HPV vaccines.

*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):
HPV Vaccine 1st dose:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of vaccination
HPV Vaccine 2nd dose:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of vaccination
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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