Virtual Renewal Application Assistance Form ENG

Value Added Service | Virtual Renewal Application Assistance

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

Cook Children’s Health Plan would like to assist you with the renewal of your benefits. A virtual home visit will be scheduled to assist you through the renewal application process and answer questions.

*Date of service must be within the current state fiscal year (September 1, 2026 - August 31, 2027)

To request this reward, please fill out this form.

Member information
Member name:
Member ID number:
Member DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Phone Number:
Format: (000) 000-0000.
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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