Tufts Health Together EXTRAS Reward Form

Tufts Health Together EXTRAS Reward Form

Tufts Health Together
EXTRAS Reward Form
Fax to: 857-304-6307
Today’s date
/
/
Important information about getting your rewards:
• Please fill out this form with your primary care provider
(PCP); specialist; or Women, Infants, and Children (WIC)
staff member.
• You must be a Tufts Health Together member when you
get services and when we process this form.
• You can request one reward for each service below once
every 12 months.
• You should get your reward 6 – 8 weeks from when we
receive this form.
• We will not process your request unless you complete this
form, have it signed by your PCP, and send it to us.
• Please fill out a separate form for each member.
Member information
Name
Address
City
Phone
Member ID #
State
-
-
ZIP
Email
PCP/Specialist (MD, DO, or RN)/WIC staff member information
Name
Address
City
Provider ID # (if applicable)
Phone
State
ZIP
-
PCP/Specialist (MD, DO, or RN)/WIC staff member to fill out and sign where noted below. Members
choose reward where noted below.
Eligible members
Kids, age 2
Provider to fill out
Member to choose one reward
Completed all of the following shots by his/her second birthday:
• 4 DTaP • 3 IPV
• 3 Hib
• 3 Rota
• 1 Hep A • 2 Influenza
• 1 Varicella • 3 Hep B
• 1 MMR • Blood lead screening • 4 PCV
$25 gift card to:
CVS
Kohl’s
Toys R Us
Walmart
$10 gift card to:
Kids, ages 3 – 9
Had a yearly checkup on:
/
/
(date of visit)
Teens, ages
10 – 18
Had a yearly checkup on:
/
/
(date of visit)
CVS
Kohl’s
$10 gift card to:
AMC Theaters
GameStop
/
/
and
/
/
CVS
Kohl’s
(dates of visits)
New mothers
Had a postpartum visit between 21 and 56 days after delivery on:
/
Members with
diabetes
/
iTunes
Toys R Us
$10 gift card to:
Visited WIC twice during pregnancy on:
Members with
asthma
Toys R Us
Walmart
Toys R Us
Walmart
$10 gift card to:
CVS
Kohl’s
(date of visit)
Toys R Us
Walmart
$10 gift card to:
Completed an asthma action plan
CVS
Kohl’s
Completed 5 routine diabetes screenings in 1 calendar year: 1 eye
exam, 2 HbA1c tests, 1 protein test, and 1 LDL test
Toys R Us
Walmart
Member gets a $25 health rewards
card
PCP/Specialist (MD, DO, or RN)/WIC staff member signature
Print name
Date
/
/
Please mail this form to:
Tufts Health Plan, Attn: Member Services, P.O. Box 9194, Watertown, MA 02471-9194
Or fax to: 857-304-6307
5246B 03096
Questions? Call us at 888-257-1985.
Voltee la hoja para la versión en español.
Tufts Health Together
Formulario de recompensas EXTRAS
Enviar por fax a: 857-304-6307
/
Fecha de hoy
/
Información importante sobre cómo recibir sus recompensas:
• Por favor llene este formulario con su proveedor primario de • Usted recibirá su recompensa entre 6 y 8 semanas después de
que recibamos este formulario.
cuidados médicos (PCP, por sus siglas en inglés),
• No procesaremos su solicitud a menos que complete y nos
especialista o miembro del personal de Mujeres, Bébes y
envíe este formulario, previamente firmado por su proveedor
Niños (WIC, por sus siglas en inglés).
primario de cuidados médicos.
• Usted debe ser miembro de Tufts Health Together en el
• Por favor llene un formulario por separado para cada miembro.
momento de recibir los servicios y cuando procesemos este
formulario.
• Usted puede solicitar una recompensa para cada servicio
siguiente una vez cada 12 meses.
Información del miembro
Nombre
N°. de ID del miembro
Dirección
Ciudad
Teléfono:
Estado
-
-
Código postal
Correo electrónico:
PCP/Specialist (MD, DO, or RN)/WIC staff member information
Name
Provider ID # (if applicable)
Address
Phone
City
State
-
-
ZIP
PCP/Specialist (MD, DO, or RN)/WIC staff member to fill out and sign where noted below. Members choose reward
where noted below. El PCP/especialista (MD, DO o RN)/miembro del personal de WIC que llenará y firmará donde se
indica a continuación. Los miembros eligen la recompensa donde se indica a continuación.
Eligible
members
Provider to fill out
Completed all of the following shots by his/her second birthday:
Kids, age 2
• 4 DTaP • 3 IPV
• 3 Hib • 3 Rota
• 1 Hep A
• 1 MMR
• 2 Influenza
• 1 Varicella • 3 Hep B
• Blood lead screening • 4 PCV
Miembro elige una recompensa
Member to choose one reward
Tarjeta de regalo de $25 para:
CVS
Kohl’s
Toys R Us
Walmart
Tarjeta de regalo de $10 para:
Kids, ages 3 – 9
Had a yearly checkup on:
/
/
(date of visit)
Teens, ages
10 – 18
Had a yearly checkup on:
/
/
(date of visit)
CVS
Kohl’s
Toys R Us
Walmart
Tarjeta de regalo de $10 para:
Visited WIC twice during pregnancy on:
and
/
/
(dates of visits)
/
/
New mothers
Had a postpartum visit between 21 and 56 days after delivery on:
/
/
(date of visit)
AMC Theaters
GameStop
iTunes
Toys R Us
Tarjeta de regalo de $10 para:
CVS
Kohl’s
Toys R Us
Walmart
Tarjeta de regalo de $10 para:
CVS
Kohl’s
Toys R Us
Walmart
Tarjeta de regalo de $10 para:
Members with
asthma
Completed an asthma action plan
Members with
diabetes
Completed 5 routine diabetes screenings in 1 calendar year: 1 eye
exam, 2 HbA1c tests, 1 protein test, and 1 LDL test
CVS
Kohl’s
Toys R Us
Walmart
El miembro recibe una tarjeta de recompensas
de salud por $25
PCP/Specialist (MD, DO, or RN)/WIC staff member signature
Print name
Date
/
/
Por favor, envíe por correo este formulario a:
Tufts Health Plan, Attn: Member Services, P.O. Box 9194, Watertown, MA 02471-9194
O por fax al: 857-304-6307
¿Preguntas? Llámenos al 888-257-1985.
5246B 03096
Turn the page over for English version.