Postpartum Visit Form ENG

Value Added Service | Postpartum Visit

*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 $50 reward once you complete one postpartum visit with an approved provider between 7 to 84 days after you deliver.

*Date of service must be within the current fiscal year (September 1, 2026 - August 31, 2027)
Member name:
(first and last name)
Member ID number:
Member DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Delivery date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Postpartum visit date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Delivery doctor name:
(first and last name)
Office phone:
Please enter a valid phone number.Format: (000) 000-0000.
Office fax:
Format: (000) 000-0000.
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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