IR21_HE001_H5433 H8016
PRI-037-319 E (12/20)
PRI-037-319 E (12/20)
Breast Cancer Screening Health Reward Form
How to qualify for the no-cost gift card:
1. Complete your breast cancer screening this year if recommended by your provider.
2. Fill out this form. Make sure your provider stamps this form.
3. Submit completed form to CalOptima before January 31 of next year. This program may be
discontinued at any time without notice.
How to submit this form to CalOptima:
► Fax: Ask your provider to fax this form on your behalf to 714-796-6613, or
► Mail:
CalOptima
Attn: Health Management
PO Box 11033
Orange, CA 92856-9902
If you qualify, it will take at least 8 weeks after we receive the completed form for you to receive
your no-cost $25 gift card.
All sections must be fully completed and stamped by the provider to receive the
no-cost gift card.
Member Name: Date of Birth:
CalOptima ID Number: Phone:
Mailing Address:
City: State: Zip Code:
Test Test Date Provider Information Provider Stamp
Mammogram
Screening
___/___/_____
Name:
Phone:
Disclaimer: You must meet all health reward eligibility requirements to qualify for the gift card. Kaiser members
are excluded. It takes at least 8 weeks after we receive the completed form to process your gift card. The gift
card cannot be used to purchase alcohol, tobacco or rearms. Gift card has no cash value, and CalOptima is
not responsible if it is lost or stolen. You may only receive 1 gift card per calendar year for this health reward.
Gift cards are available while supplies last. This health reward may be discontinued at any time without notice.
OneCare (HMO SNP) is a Medicare Advantage Organization with a Medicare contract. Enrollment in OneCare
depends on contract renewal. OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) is a health
plan that contracts with both Medicare and Medi-Cal to provide benets of both programs to enrollees. OneCare
and OneCare Connect comply with applicable Federal civil rights laws and does not discriminate on the basis of
race, color, national origin, age, disability, or sex.
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IR21_HE001_H5433 H8016
PRI-037-319 E (12/20)
