Medicare Advantage Preventive Care Visit Reward Program

Medicare Advantage Preventive Care Visit Reward Program

We want to make sure that, as a Health New England member, you are receiving quality care. Once you’ve had your 2025 Preventive Care Visit, please complete this brief form and submit it by 12/31/25 to receive your $20 reward. Please tell us about your visit below:
Member Name*

First NameLast Name
Member ID#*
This is an 11 digit number which start with a 9 and ends in a 01
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Care Provider Name*
Practice Name
Date of 2025 Well-Care Visit or Physical Exam*

MonthDayYear
Date
Did you receive an Adult Well-Care Visit or a Physical?*

Adult Well-Care Visit (In-Office)PhysicalAdult Well-Care Visit (Telehealth)I don't know
Which of the following topics did your Primary Care Provider (PCP) discuss with you during your visit? (check all that apply):*

Physical HealthRisk of FallingAdvance Care PlanningMental HealthUrinary Incontinence
How satisfied are you with your Preventive Care Visit?*

Very SatisfiedSomewhat SatisfiedNot Satisfied
How satisfied are you with your Preventive Care Visit?

Very SatisfiedSomewhat SatisfiedNot Satisfied
Was this your first visit with this PCP?*

Yes, this was my first visit with this PCPNo, I have visited this PCP before

Overall, how would you rate your PCP?*

	1	2	3	4	5

1 is Worst, 5 is Best

How satisfied are you with your experience scheduling your Preventive Care Visit?*

Very SatisfiedSomewhat SatisfiedNot Satisfied
How satisfied are you with your experience scheduling your Preventive Care Visit?

Very SatisfiedSomewhat SatisfiedNot Satisfied
What is the likelihood you will receive your Preventive Care Visit next year?*

Very LikelySomewhat LikelyNot Likely
What is the likelihood you will receive your Preventive Care Visit next year?

Very SatisfiedSomewhat SatisfiedNot Satisfied
How did you learn about this Preventive Care Visit reward?*

HNE Wellness CalendarHealthMatters GuideEmailNewsletter ArticleDoctor ReferralReminder LetterHNE Member Services RepresentativeOther
Please select your $20 reward:*

CVS SelectWalmartDunkin'
Please select your $20 reward:

CVS SelectAmazonDunkin'
Health New England is not affiliated, associated, authorized, endorsed by, or in any way officially connected with Amazon, CVS, Dunkin', or any of their respective subsidiaries and/or affiliates.

©2019 DD IP Holder LLC. The Dunkin’ Donuts trademarks/trade dress are owned by DD IP Holder LLC and used under license. Dunkin’ Donuts is not a sponsor of this promotion.
Should be Empty: