Member Rewards

**Your Molina Rewards for 2020 may be submitted through January 31, 2021.**

Stay tuned for news on 2021 rewards coming soon!

New forms are now available for the Molina Member Rewards Program! It's easier than ever to fill out the forms. A provider signature is no longer required.

To earn an Gift Card, please fill out the appropriate form(s) below to tell us about the health screening(s) you have received.

  • There are individual forms for each reward-related child and adolescent screening, and for each adult screening.

  • Plus, for adults there is a Combined Member Form that contains all of the reward-related adult screenings, should you prefer to fill that out instead of separate forms.


For more information about Molina's Member Rewards Program, see our flyer.

You can then 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


Attention Molina Quality Team at (800) 461-3234

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

Check out the forms below:

2020 Combined Member Form (for more than 1 adult screening)

2020 Breast Cancer Screening Member Form

2020 Cervical Screening Member Form

2020 Diabetes Screening Member Form

2020 Prenatal Visit Member Form

2020 Postpartum Visit Member Form

2020 Childhood Immunizations Member Form

2020 15 Month Well-Child Checkups Member Form

2020 3-6 Year Well-Child Checkups Member Form

2020 Adolescent Well-Care Member Form