Florida Medicaid Healthy Behavior Incentive Form

To get your $20 Amazon gift card you must:

Receive one of the qualifying services below within the first 180 days of enrollment with DentaQuest.
Complete and submit this form.

Please briefly explain your license request below

Check the qualifying service(s) you received:

Dental checkup Topical fluoride treatment Molar(s) sealed

Date of service

Member Information

First Name

Last Name

Date of Birth

Mailing address

City

Zip code

Member ID Number

Phone

The newsletter designed for anyone who wants to improve oral health for themselves, their families, customers or communities.