Care Gap Form

You may be eligible for a reward! My Health Pays™ reward dollars are added to your rewards card after we process the claim for each activity completed. If you are earning your first reward, your My Health Pays™ Visa® Prepaid Card will be mailed to you.

Participant Name: *

Participant Phone Number: *

Participant Date of Birth: *

PAS Worker Name: *

PAS Worker Phone Number: *

Primary Care Provider: *

Breast Cancer Screening:

Did you complete your Breast Cancer Screening? *

Date of Screening:

Where was the screening completed?

Colonoscopy:

Did you complete your Colonoscopy Screening? *

Date of Screening:

Where was the screening completed?

Cervical Cancer Screening:

Did you complete your Cervical Cancer Screening? *

Date of Screening:

Where was the screening completed?

Diabetic Eye Exam:

Did you complete your Diabetic Eye Exam? *

Date of Screening:

Where was the screening completed?

Additional Assistance is Available:

Assistance with scheduling appointments	In home diabetic kidney function test
Assistance with selecting a primary care provider	In home diabetic eye exam
In home colorectal cancer screening test	Transportation
In home diabetic HbA1c test

Call for assistance Monday through Friday 8 a.m. to 5 p.m. 917-454-6976 (TTY: 711). Please leave your name, phone number, and best time to call back.