South Carolina Form

Molina Healthcare of South Carolina would like to THANK YOU for making your health a priority!

To redeem your gift card please complete your health screening(s) as soon as possible, and complete the following information below. Click submit to send to Molina. Gift card fulfillment is typically 6-8 weeks.

(*) Indicates a required field.

*Member First Name:

Please enter your first name

*Member Last Name:

Please enter your last name

*Member HealthPlan ID:

Please enter your Molina Healthcare ID found on your insurance card

*Mailing Address Line1:

Please enter your mailing address

Mailing Address Line2:

Please Fill Mailing Address Line2

*Mailing City:

Please enter your mailing city

*Mailing State:

Please Fill Mailing State.

*Zip:

Please enter your zip code

*Primary Phone Number:

Please enter a phone number E.g. xxx-xxx-xxxxPlease fill a valid phone number e.g. (xxx) xxx-xxxx Opt-in to text for future communication

Secondary Phone Number:

Please fill requestor phone ( E.g (xxx)-xxx-xxxxx ).Please fill a valid phone number e.g. (xxx) xxx-xxxx Opt-in to text for future communication

Best Time to Reach You:

Email:

Pregnancy and Baby Rewards:

*Are you completing this form for the
Pregnancy or Baby reward?

Yes No

Please select one option

Screening:

Appointment Date:

Provider Office or Doctor's Name:

Add +

Additional screenings may be added at a later time in the year as they are completed

Annual Screening Rewards:

*Are you completing this form for
the Annual Program Rewards?

Yes No Please select one option

Annual Screenings must be completed no later than December 31, 2023. Requested information must be completed no later than January 19, 2024.

Screening:

Appointment Date:

Provider Office or Doctor's Name:

Add +

Additional screenings may be added at a later time in the year as they are completed

Molina Healthcare of South Carolina would like to THANK YOU for making your health a priority!

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