PRI-037-366 E (12/20)
Diabetes Eye Exam Health Reward Form
How to qualify for the no-cost gift card:
1. Complete your diabetes eye exam this year. You should get your diabetes eye exam (dilated
or retinal) done every year by your eye doctor.
2. Fill out this form. Make sure your eye doctor 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:
Diabetes
Type
Diabetes
Exam Date
Exam Results Provider Information Provider Stamp
o Type I
o Type II
___/___/____
Retinopathy?
o Yes o No
Shared with PCP?
o Yes o No
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.
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