Housing Deposit Fee Form ENG

Value Added Service | Housing Deposit Fee

*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 $125 gift card for your housing deposit fee for a house, an apartment or hotel room. Each member within the household must complete the Initial Health Needs Screening within 30 days of enrollment.

*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
Parent phone number:
Format: (000) 000-0000.
Provider name (last, first):
This benefit is limited to one gift card per household, per family, per year. Proof of payment will be required. You may email proof of payment to cchpcustomersvc@cookchildrens.org. Please include in your email the member’s name and Member ID number. All information must be clear and complete.
File Upload

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Please call Cook Children’s Health Plan to speak to Case Management to receive assistance.

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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