South Carolina Form

Thank you for making your health a priority! Molina Healthcare of South Carolina members who make healthy choices are rewarded with free value add benefits.

Please complete the following form if either of the following applies to you:

You are pregnant or a new mom who completed your telephonic health screening and wants free meals from the Mom's Meals program.
You have an 8, 9, or 10-year-old who has completed a well visit this year, and you'd like them to be rewarded with a new bike and helmet.

(*) Indicates a required field.

*Member First Name:

Please enter your first name

*Member Last Name:

Please enter your last name

*Member Health Plan ID:

Please enter your Molina Healthcare ID found on your insurance card

*Mailing Address Line1:

Please enter your mailing address

Mailing Address Line2:

Please Fill Mailing Address Line2

*Mailing City:

Please enter your mailing city

*Mailing State:

Please Fill Mailing State.

*Zip:

Please enter your zip code

*Primary Phone Number:

Please enter a phone number E.g. xxx-xxx-xxxxPlease fill a valid phone number e.g. (xxx) xxx-xxxx Opt-in to text for future communication.

Email:

2024 Value Adds – Select the option that applies to you

Mom's Meals - Click here only AFTER completing the telephonic health screening

Delivery Date of Baby:

Postpartum Appointment Date (If Applicable):

Provider Office or Doctor's Name:

Get a Handle on Health Bicycle & Helmet

Well Visit Appointment Date:

Provider Office or Doctor's Name:

You must provide all required information requested above as soon as possible, or no later than February 28, 2025. Submission of this form does not guarantee that you will receive an incentive. All services are verified through claims data or medical records before incentives are awarded.

Thank you for making your health a priority! Molina Healthcare of South Carolina members who make healthy choices are rewarded with free value add benefits.

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