Notificación de embarazo para miembros

Los campos marcados con * son obligatorios

Member Notification of Pregnancy Form

This form is confidential. We share this information with our care management teams to help manage your care. This form tells us what we need to know to help you achieve a healthy pregnancy.

Once you complete the form, you will earn a $50 reward on your CountyCare Visa Rewards Card.
Our care management team will reach out to you once you submit this form.

Follow these steps:
Step 1: Complete all member information
Step 2: Complete the prenatal care provider information.
Step 3: Submit the form.

Are you Pregnant? *

Yes
No

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Evaluación de riesgos para la salud de los miembros

Los campos marcados con * son obligatorios

Member Health Risk Screening

This form is confidential. We share this information with our care management teams to help manage your care. This form tells us what we need to know to help you on your health journey.

Once you complete the form, you will earn $50 on your CountyCare Visa Rewards Card. Our care management team may reach out to you once the form is submitted.

Follow these steps:

Step 1: Complete all member information
Step 2: Complete all questions within the health survey
Step 3: Submit the form

Are you a CountyCare member of at least 13 years old? *

Yes
No

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This form is for CountyCare members ages 13 years and older. Parents or guardians can complete the survey on behalf of their minor children by texting the word "SURVEY" to 47181 and entering their child's Member ID and Date of Birth or by calling Member Services at 312-864-8200, toll-free at 855-444-1661, or 711 (TTY)

Chicago Family Health

abril 2025

Evento de redeterminación de CountyCare

Miembros

Portal de miembros

Proveedores

Portal de proveedores

Encuentra un proveedor

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CountyCare?

Sobre nosotros

Carreras

Member Notification of Pregnancy Form

Member Health Risk Screening