AETNA BETTER HEALTH® OF VIRGINIA Schedule your child`s

AETNA BETTER HEALTH® OF VIRGINIA
9881 Mayland Drive
Richmond, VA 23233
This is general health information and should
not replace the advice or care you get from your
provider. Always ask your provider about your own
health care needs. Esta es información general
de salud y no debe reemplazar el asesoramiento
o la atención que usted recibe de su proveedor.
Siempre consúltele a este sobre sus necesidades
de atención médica.
www.aetnabetterhealth.com/virginia
VA-16-05-11
AETNA BETTER HEALTH® OF VIRGINIA
Schedule your child’s yearly well visit
Back to School and time for your child’s yearly well exam
Aetna Better Health of Virginia is working with our pediatricians to ensure that all our members get their yearly well
exams. Children and teenagers can get a head to toe well-child exam, immunizations and screenings with their
doctor at no cost to you. Schedule your child’s appointment today. Members that complete this visit by
August 31, 2016 will be entered in a drawing for a “Back-To- School” backpack and school supplies.*
*One gift per member, per qualifying year. Must be an Aetna Better Health of Virginia member at the time of the visit
and when the drawing entry is requested.
www.aetnabetterhealth.com/virginia
Incentive form
Member name (print) ______________________________________________________________________________________________
Member ID # __________________________________________________________________________________________________________
Address _________________________________________________________________________________________________________________
City __________________________________________________________________ State ________ Zip Code _____________________
Phone number _______________________________________________________________________________________________________
Member Date of Birth _____________________________________________________________________________________________
Check services
completed on date of
visit:
❏❏ Well child exam/
physical
❏❏ BMI Percentile
Doctor’s Name (Print) _____________________________________________________________________________________________
❏❏ Physical activity
counseling
Provider ID # __________________________________________________________________________________________________________
❏❏ Nutrition counseling
Address _________________________________________________________________________________________________________________
❏❏ Catch-Up
Immunizations
Address 2_______________________________________________________________________________________________________________
City __________________________________________________________________ State ________ Zip Code _____________________
Phone number _______________________________________________________________________________________________________
❏❏ Meningococcal
vaccine
Doctor’s Signature __________________________________________________________________________________________________
❏❏ HPV vaccine
Date of visit ____________________________________________________________________________________________________________
❏❏ Td Booster Vaccine
Please return this completed form in a self-addressed stamped envelope to:
Aetna Better Health of Virginia, 9881 Mayland Drive, Richmond, VA 23233
Note: One entry per person, per qualifying year.