Well Child Visit Form ENG

Value Added Service | Well Child Visit

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

Cook Children’s Health Plan cares about the health of your child. We want to make sure your child gets the checkups he or she needs for proper growth and development.

Your child can be eligible for one of these rewards:

One $25 gift card for members age 2 to 19 who complete an annual well visit (CHIP members only)

OR

A $25 gift card for members who complete a well visit at 2 weeks, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months or 18 months of age ($25 gift card for each visit, maximum $200)

Cook Children’s Health Plan will check to see that the visit took place.

*Date of service must be within the current state fiscal year (September 1, 2026 - August 31, 2027).
Member name:
By filling out this form, you are attesting that the person above has completed their annual well checkup visit
Member ID number:
Member DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Provider name:
Date of visit:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
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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