Well Woman Screening Form ENG

Value Added Service | Well Woman Screening

*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 reward for Members ages 16 and older who had a test:

• Cervical cytology test
• Cervical high risk human papilloma virus (hrHPV) testing
• Cervical cytology/hrHPV co-testing, or
• Chlamydia testing

*Date of service must be within the current state 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
Provider name:
(first and last name)
Date of service:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Name of test:
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: