Apple Health (Medicaid) Member Rewards 

2022 Apple Health Molina Member Rewards Program!

Note: Your Molina Rewards for 2022 may be submitted through January 31, 2023.

Forms are now available for the 2022 Molina Member Rewards Program! It’s easier than ever to fill out the forms. A doctor’s signature is not required.

Child Forms

  • Well-Child Visits for 30-Month-Olds 
  • Childhood Immunizations (a copy of the immunization record is required)
  • Well-Care Visits for Ages 3-11
  • Attention-Deficit/Hyperactivity Disorder (ADHD) Medication Follow-Up Visit

Preteen and Young Adult Forms

  • Immunizations for Adolescents (a copy of the immunization record is required)
  • Well-Care Visits for Ages 12-21
  • Chlamydia Screening for Women Ages 16-24 

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 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:

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


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

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 2022 Member Form

Childhood Immunizations 2022 Member Form

3-11 Year Well-Care Visits 2022 Member Form

ADHD Medication Follow-Up Visit 2022 Member Form

Immunizations for Adolescents 2022 Member Form

12-21 Year Well-Care Visits 2022 Member Form

Chlamydia Screening 2022 Member Form

Prenatal Visit 2022 Member Form

Postpartum Visit 2022 Member Form

Breast Cancer Screening 2022 Member Form

Cervical Screening 2022 Member Form

Diabetes Screening 2022 Member Form

Combined 2022 Member Form (for more than 1 adult screening)

The deadline to submit reward forms for visits completed in 2021 is January 31, 2022. Forms received after the deadline will not be processed.