Login / Register
Contact Us
Help
Wellcare National
Community Resources

English

Enter Keyword

Members
Providers
Corporate
Find a Provider / Pharmacy
Become a Provider

Members
Providers
Corporate
Find a Provider / Pharmacy
Become a Provider

Login / Register
Contact Us
Help
Wellcare National
Community Resources

English

Medicaid
Member Portal Login
QUEST (Medicaid)
Community Care Services Plan

My Health Pays Rewards Program Form

MY HEALTH PAYS REWARDS SELF-ATTESTATION FORM

‘Ohana Health Plan is excited to offer you rewards for completing a 2026 My Health Pays activity. The activity must have happened between 1/1/26 - 12/31/26.
Please fill out the member info, check the box of the activity you completed, and press submit to process your reward. If you need help filling out the form online we are available to help you. Call Customer Service toll-free at 1-888-846-4262 (TTY: 711).

To ensure your 2025 rewards are properly credited, members must self‑attest for rewards by February 28, 2026.*Please note updating contact information is not a retroactive reward and will not be eligible for self-attestation.*

Member Information

I am a: *

Error: Please choose an option from the "I am a:" section. This is required to proceed.

First Name: *

Error: Please fill out the First Name field.

Last Name: *

Error: Please fill out Last Name field.

Date of Birth *

Error: Please select your Date of Birth.

Member ID:

My Health Pays Activity Rewards

The activity must have happened between 1/1/26 - 12/31/26. If you need more information about what rewards you can receive, visit the My Health Pays Rewards Program page..

Click the activity that you have completed:

Please Select Update my address and contact information ($10, once per year, $50 max per household) Annual Wellness Visit ($40); once per year Infant Well-Child Visit for 0 - 14 months old ($60); must have all SIX required visits before 15 months of life Infant Well-Child Visit for 15 - 30 months old ($20); must have both TWO required visits between 15 - 30 months of life Notification of Pregnancy ($75) Postpartum Depression Screening Completed ($25)

Error: This field is required.

Update My Address and Contact Information

Address 1: *

Error: This field is required.

Address 2:

City: *

Error: This field is required.

State: *

Error: This field is required.

Zip Code: *

Error: This field is required.

Phone Number: *

Error: This field is required.

Email Address:

Error: This field is required.

Preferred Method of Communication:

Please Select Option: Currently Houseless – This will be the best contact address and phone number to reach me at. Not Currently Houseless

Error: This field is required.

Annual Wellness Visit

Appointment Date *

Error: The Appointment Date is a required field.

Doctor's Name *

Error: The Doctor's Name field is required.

Infant Well-Child Visit for 0-14 months old

Appointment Date #1 *

Error: Appointment Date 1 is a required field.

Appointment Date #2 *

Error: Appointment Date 2 is a required field.

Appointment Date #3 *

Error: Appointment Date 3 is a required field.

Appointment Date #4 *

Error: Appointment Date 4 is a required field.

Appointment Date #5 *

Error: Appointment Date 5 is a required field.

Appointment Date #6 *

Error: Appointment Date 6 is a required field.

Doctor's Name(s) *

Error: The Doctor(s) Name field is required.

Infant Well-Child Visit for 15-30 months old

Appointment Date #1 *

Error: Appointment Date 1 is a required field.

Appointment Date #2 *

Error: Appointment Date 1 is a required field.

Doctor's Name(s) *

Error: The Doctor(s) Name field is required.

Notification of Pregnancy

Estimated Due Date: *

Error: This field is required.

Are you currently seeing an OB for your pregnancy? No Yes

Error: This field is required.

Name of your OB provider: *

Error: This field is required.

Postpartum Depression Screening Completed

Service Date *

Error: This field is required.

Clinic/Doctor's Name(s)

I attest required * I attest that the information provided above is true and accurate, to the best of my knowledge. I understand that 'Ohana Health Plan reserves the right to verify and audit the above information for accuracy and material misrepresentations may result in recoupment of reward dollars.

Error: Attestation Required.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

Find a Provider
Member Login
Contact Us
Help
Careers

Accessibility
Privacy & Legal
Notice of Non-Discrimination

If you are unable to view PDFs, please download Adobe Reader.