Your health and well-being is our #1 concern at Harbor Health Plan. We offer gift card incentives for some of the
care and services you receive by your doctor. Here is a list of the incentives you may be eligible for when you
receive these services before the end of the year or time specified.
Gift cards are sent when doctor sends in a copy of the exam or results.
Gift Card
Well Child Service
Amount
Well Child exams for children ages 0-15 months (6 exams by 15 months old)
$100
Well Child exam for children ages 3-6 years old (1 exam)
$25
Well Child exam for children ages 12-21 years old (1 exam)
$25
nd
Childhood immunizations required for your child 0-2 years old (before child’s 2 birthday)
$100
Lead Testing by the age of 2
$25
Wo men ’s Hea lth Services
Pap Smear (ages 21-64)
$50
Mammogram/Breast Screening (ages 40-74)
$50
Chlamydia Screening (sexually active ages 16-24)
$25
If you have Diabetes
Eye exam by your eye doctor
$25
Blood Pressure Check
$25
A1C (blood sugar test)
$25
Additional Medical Services
Adult Access to Care
$50
Body Mass Index (BMI) Adult (ages 18-74) BMI Percentile Child (ages 3-17)
$25
Patient Name:________________________________________
Patient Address:______________________________________
Patient ID#:___________________________________________
Patient DOB: ________________________________________
Doctor Name:________________________________________
Doctor Phone:________________________________________
Appointment Date:____________________________________
Appointment Time:___________________________________
Harbor Health Plan Missing Services
Harbor Health Plan cares about your health.
Below are services you are missing (see check boxes)
Take this form to your Doctor to fill out.
Must be a member on the date of service.
THE DOCTOR MUST SEND A COPY OF RESULTS / EXAM TO HARBOR HEALTH PLAN (address below)
Well Child Services:
� Adult Access to Care Visit Date of Service:___________________
� Well Child Exam for children ages 0-15 Months (Total of 6 exams)
Dates of Service:
/
/
/
/
Well
Child
Exam
for
children
ages
3-6
years
(Total
of
1
exam)
�
Date of Service: ___________________________
� Well Child Exam for children ages 12-21 years (Total of 1 exam)
Date of Service: ___________________________
� Childhood immunizations when required for children 0-2 years ( Attach Copy of shot Record)
Date Tested:
Result:
� Lead Testing before 2nd birthday
Women's Health Services for 2016:
Date of Service:
� Pap Smear (ages 21-56)
Date of Service:
� Mammogram/Breast Screening (ages 40 -74)
� Chlamydia Screening (sexually active ages 16-24) Date of Service:
Result:
Result:
Result:
If you have Diabetes:
� Eye exam by your eye doctor
� Blood Pressure Check
� A1C (blood sugar test)
Result:
Result:
Result:
Date of Service:
Date of Service:
Date of Service:
/
Additional Medical Services:
� Body Mass Index (BMI), Height & Weight Adult (ages 18-74) BMI Percentile Child (ages 3-17)
(Measure Weight Compared to Height)
Adult Date of Service:____________________
BMI Results_________________
Height Results: _________________________
Weight Results:______________
Child Date of Service:____________________
BMI %ile Results:____________
Nutrition Discussion DOS:_________________
Physical Activity Discussion DOS:_______________
If you need transportation to your doctor's office, please call 1-844-427-2671
Please mail completed form along with a COPY of the exam record to:
OR Fax to: 313-578-3760 Attn: Quality Management Department
Please Call 313-578-3785, if you have any questions.
Harbor Health Plan
Attn: Quality Management Dept
3663 Woodward Ave., Suite 120
Detroit, MI 48201
Doctor's Signature:_______________________________
Date:__________________________
Office Contact Name:_____________________________
Phone_________________________