Member Rewards

There are exciting updates to the Molina Member Rewards Program!

Note: Your Molina Rewards for 2021 may be submitted through January 31, 2022.

Forms are now available for the 2021 Molina Member Rewards Program! It’s easier than ever to fill out the forms. A doctor’s signature is not required. Some rewards have been updated and new screenings have been added.

Child Forms

  • Well-Child Visits for 30-Month-Olds (Expanded to include 30-month-olds)
  • Childhood Immunizations
  • Well-Care Visits for Ages 3-11 (Expanded to include ages 7-11)
  • Attention-Deficit/Hyperactivity Disorder (ADHD) Medication Follow-Up Visit (NEW)

Preteen and Young Adult Forms

  • Immunizations for Adolescents (NEW)
  • Well-Care Visits for Ages 12-21
  • Chlamydia Screening for Women Ages 16-24 (NEW)

Maternity Forms

  • Prenatal Visit
  • Postpartum Visit

Cancer Screening Forms

  • Breast Cancer Screening
  • Cervical Cancer Screening

Diabetes Screening Forms

  • Diabetes HbA1c Test Result Less than 8
  • Diabetes Eye Exam

To earn an Amazon.com Gift Card, please fill out the appropriate form(s) below with details of the health screening(s) you have received.

  • There are individual forms for each child and adolescent screening, and for each adult screening
  • There is also a Combined Member Form that contains all of the adolescent and adult screenings, if you prefer to fill that out instead of separate forms


For more information on the Molina Member Rewards Program, see our flyer.

You can submit the form(s) to us in any of the following ways:

Mail
Molina Healthcare
Attn: Quality Team
P.O. Box 4004
Bothell, WA 98041-4004

Email
MHW_QI_Interventions@MolinaHealthcare.com

Fax
Attn: Molina Quality Team at (800) 461-3234

Phone
Call us at (800) 869-7175, ext. 141428, and provide details of the visit you have completed.


Print the form(s) you need below or call/email us with your screening details (a copy of your child’s immunization record is required for immunization rewards):

30 Month Well-Child Visits 2021 Member Form

Childhood Immunizations 2021 Member Form

3-11 Year Well-Care Visits 2021 Member Form

ADHD Medication Follow-Up Visit 2021 Member Form

Immunizations for Adolescents 2021 Member Form

12-21 Year Well-Care Visits 2021 Member Form

Chlamydia Screening 2021 Member Form

Prenatal Visit 2021 Member Form

Postpartum Visit 2021 Member Form

Breast Cancer Screening 2021 Member Form

Cervical Screening 2021 Member Form

Diabetes Screening 2021 Member Form

Combined 2021 Member Form (for more than 1 adult screening)

The deadline to submit reward forms for visits completed in 2020 was January 31, 2021. Forms received after the deadline will not be processed.