Claim Your Health First Colorado or Child Health Plan Plus Healthy Behavior Rewards

Please briefly explain your license request below

Member Incentive Type

Member Incentive Type - Check all that Apply $20 Amazon Gift Card—Oral Health Risk Screening Form Within 90 Days of Enrollment $20 Amazon Gift Card—Preventive Visit Within 90 Days of Enrollment $20 Amazon Gift Card—Sealant Visit $20 Amazon Gift Card—Two Preventive Dental Visits in a 12-Month Period $35 Amazon Gift Card—Opioid Risk Assessment and Education Following Tooth Extraction

Remember to complete the Oral Health Risk Assessment and the Healthy Behaviors Incentive Form below to claim your reward. If you do not complete the Oral Health Risk Assessment and this form, you will not qualify for the Oral Health Risk Screening Form Within 90 Days of Enrollment Gift Card.

Remember to watch an opioid safety and pain management video and complete the Opioid Risk Assessment to claim your reward. If you do not complete the Opioid Risk Assessment, you will not qualify for the Opioid Risk Assessment and Education Following Tooth Extraction Gift Card.

Member's Information

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Date Member received care

Member ID Number