2025 Maternal Incentive - Prenatal Visit Form

Earn a $30 gift card when you complete this form.

To receive this reward, you must be a Priority Health Medicaid member. You must complete a prenatal visit with a provider* within the first 12 weeks of pregnancy (1st trimester). Prenatal visits are covered at no-cost to you.

Your gift card will be delivered via email once we receive your medical claim.

*Provider can include a Primary Care Provider (PCP), OB/GYN, physician, Certified Nurse Midwife (CNM), Nurse Practitioner (NP), or Physician’s Assistant (PA)

Personal Information

1. Full Name *This question is required.

2. Please enter your Priority Health Contract ID (found on the front of your Priority Health Member ID card) or Medicaid ID (found on the front of your mihealth card). *This question is required.

3. Please re-enter your Priority Health Contract ID or Medicaid ID *This question is required.

4. Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

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5. Phone Number *This question is required.

6. Active Email Address (your $30 gift card will be sent to you via this email) *This question is required. This question requires a valid email address.

7. Mailing Address *This question is required.

Prenatal Visit Information

8. Estimated Due Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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9. Provider*/ Name of Facility *This question is required. *Provider can include a Primary Care Provider (PCP), OB/GYN, physician, Certified Nurse Midwife (CNM), Nurse Practitioner (NP), or Physician’s Assistant (PA)

10. Date of Prenatal Visit *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Resources
Want to learn more about our no-cost maternity programs and resources? Check all that apply. Our team will contact you.

11. Preferred Language

Please enter an 'other' value for this selection.

12. I am interested in learning more about:

Doula care: A doula helps you manage your health and ensures a comfortable birthing experience. They can also provide you support during the first few weeks of postpartum.
PriorityMOM: Receive free gifts, cost and coverage information and education to help manage your pregnancy.
PriorityBABY: Receive educational information during the first 24 months of your infant’s journey.
MIHP (Maternity and Infant Health Program): Provides regular in-home visits by a nurse, social worker or dietician.
WIC (Women, Infants, and Children Program): This health and nutrition program support your family during pregnancy and child development.