Diabetes A1C Test Health Reward Form
How to qualify for the no-cost gift card:
1. Complete your A1C test this year. Talk to your provider about how often you should get tested.
2. Fill out this form. Make sure your provider or the lab 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
Test Test Date
A1C
Value
Provider Information Provider Stamp
o Type I
o Type II
A1C ___/___/____
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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