Tufts Health Direct EXTRAS Reward Form

Tufts Health Direct
EXTRAS Reward Form:
Health Rewards Card
Fax to: 781-393-3530
Today’s date
/
/
Important information about getting your health rewards card:
• You can request:
o One $55 health rewards card for getting your yearly checkup every 12 months
o One $25 health rewards card for getting five diabetes screenings every 12 months
• You must be a Tufts Health Direct member when you see your doctor and when we process this form.
• You should get your health rewards card 6 – 8 weeks from when we receive this form.
• We will not process your request unless you complete this form, have it signed by your doctor, and send it to us.
• Please fill out a separate form for each member.
Member information
Name
Address
City
Phone
Member ID #
State
-
-
ZIP
Email
Primary care provider (PCP)/Specialist (MD, DO, or RN) information
We must have your provider’s name and ID # to process this form.
Name
Address
City
Phone
Email
Provider ID #
State
ZIP
PCP/Specialist (MD, DO, or RN) to fill out and sign this section
I confirm that the Tufts Health Direct member above:
/ / (date of visit)
Had a yearly checkup on
Member gets a $55 health rewards card. Qualifying CPT codes for reward: 99385 – 99387, 99395 – 99397,
99401 – 99404, 99411, 99412, 99420, and 99429
Has a diabetes diagnosis and completed five routine diabetes screenings in one calendar year
Member gets a $25 health rewards card. Member must have completed each of the following: one eye exam,
two HbA1c tests, one protein test, and one LDL test.
PCP/Specialist (MD, DO, or RN) signature
Date
/
/
Print name
Please mail this form to:
Tufts Health Plan
Attn: Member Services
P.O. Box 9194
Watertown, MA 02471-9194
Or fax to: 781-393-3530
5252 08115
Questions? Call us at 888-257-1985.
Voltee la hoja para la versión en español.
Tufts Health Direct
Formulario de recompensas EXTRAS:
Tarjeta de recompensas de salud
Enviar por fax a: 781-393-3530
/
Fecha de hoy
/
Información importante sobre cómo recibir la tarjeta de recompensas de salud:
• Usted puede solicitar:
o Una tarjeta de recompensas de salud por $55 para recibir su control anual cada 12 meses
o Una tarjeta de recompensas de salud por $25 para recibir cinco exámenes de detección de diabetes cada
12 meses
• Usted debe ser miembro de Tufts Health Direct en el momento de la visita al médico y cuando procesemos este
formulario.
• Usted recibirá su tarjeta de recompensas de salud entre 6 y 8 semanas después de que recibamos este formulario.
• No procesaremos su solicitud a menos que complete y nos envíe este formulario, previamente firmado por su
médico.
• Por favor llene un formulario por separado para cada miembro.
Información del miembro
Nombre
Dirección
Ciudad
Teléfono
N°. de ID del miembro
Estado
-
-
Código postal
Correo electrónico
Información del proveedor primario de cuidados médicos (PCP, por sus siglas en inglés)/especialista (MD,
DO o RN)
Debemos tener el nombre de su proveedor y el N°. de ID para procesar este formulario.
Nombre
N°. de ID del proveedor
Dirección
Ciudad
Estado
Código postal
Teléfono
Correo electrónico
PCP/Specialist (MD, DO, or RN) to fill out and sign this section
I confirm that the Tufts Health Direct member above:
/ /
(date of visit)
Had a yearly checkup on
Member gets a $55 health rewards card. Qualifying CPT codes for reward: 99385 – 99387, 99395 – 99397,
99401 – 99404, 99411, 99412, 99420, and 99429
Has a diabetes diagnosis and completed five routine diabetes screenings in one calendar year
Member gets a $25 health rewards card. Member must have completed each of the following: one eye exam,
two HbA1c tests, one protein test, and one LDL test.
PCP/Specialist (MD, DO, or RN) signature
Date
/
/
Print name
Por favor, envíe por correo este formulario a:
Tufts Health Plan
Attn: Member Services
P.O. Box 9194
Watertown, MA 02471-9194
O por fax al: 781-393-3530
5252 08115
¿Preguntas? Llámenos al 888-257-1985.
Turn the page over for English version.