$20 value
Healthy Pregnancy Checkup: Prenatal Care Visit
You can earn $20 when you attend 6 or more prenatal visits before the birth of the baby. Please print this form and complete the information with your health care provider.
TO BE COMPLETED BY MEMBER
Member ID # Date of Appointment
First Name Last Name
Member Mailing Address City, State and ZIP
Please note: The Healthy Rewards Program runs from June 1, 2015, through June 1, 2017. All activities must be completed and returned during this time. Incomplete vouchers will not be honored. Please allow 4–6 weeks for your gift card to arrive in the mail.
TO BE COMPLETED BY HEALTH CARE PROVIDER Date of Appointment
Provider ID Number Provider Signature
Please fax to: 1-813-452-5124, Georgia Medicaid Retention, or email [email protected].
Questions? Call us at 1-866-231-1821. TTY users may call 1-877-247-6272. We’re here Monday–Friday from 7 a.m. to 7 p.m. Or visit www.wellcare.com/Georgia.
GA033698_CAD_FRM_ENG State Approved 03182016 ©WellCare 2016 GA_04_16_HPRE
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WellCare proudly serves Georgia Families®, PeachCare for Kids® and Planning for Healthy Babies® members.
