Florida Medicaid Healthy Behavior Incentive Form

To get your $20 Walmart gift card,

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

Check the qualifying service(s) you received:
Members ages 0-20:

Dental checkup
Topical fluoride treatment
Molar(s) sealed

Date of Service:

Member Information

First Name:

Last Name:

Date of Birth:

Mailing address:

City:

State:

Phone:

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