Prenatal Visits Form ENG

Value Added Service | Prenatal Visits

*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 reward after you complete your prenatal visits. You can get $25 for completing each of the visits below (up to $100).
- One prenatal visit within the first trimester or 42 days of enrollment
- A visit within the third month of your pregnancy
- A visit within the sixth month of your pregnancy
- A visit within the ninth month of your pregnancy
Remember, you can only receive one $25 gift card per visit. Each appointment can take up to 90 days to verify, so thank you for your patience.

*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
Doctor/Nurse name:
(first and last name)
Office phone:
Please enter a valid phone number.Format: (000) 000-0000.
Office fax:
Please enter a valid fax number.Format: (000) 000-0000.
Would you like to receive more information on breastfeeding?
Select one (per form):
Est. due date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year1st visit ONLY
Est. gestational age:
1st visit ONLY
Visit date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.
Should be Empty: