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GET FIT! GIFT COUPON Prenatal Education Rewards Program

For University of California members

Dear UC Health Net parent-to-be: Health Net cares about you and your new baby's health and safety. For this reason, Health Net will provide you with an incentive for the Pregnancy Matters program. In addition to receiving the UC Wellness $40 Gift Card Incentive, you will also receive an additional gift from Health Net when you complete a prenatal or well baby education class at your participating physician group (PPG), hospital or education facility. Upon completion, we will reward you with a $40 gift card that can be redeemed at any Toys R Us or Kids R Us store. Please complete this Prenatal Education Rewards Program attendance verification form so we can send your gift card. Please be advised that these gift cards will arrive separately. Please allow 4-6 weeks for processing. You must be a UC Health Net member to receive both of these gift cards.

IMPORTANT! Your gift cards will be delayed if the information below is incomplete or not clearly printed.

MEMBER MAILING INFORMATION

NAME (please print) DUE DATE E-MAIL1

ADDRESS

APT

CITY

STATE

ZIP

SUBSCRIBER ID#

TELEPHONE #

PPG/PHYSICIAN VERIFICATION OF EDUCATION

PPG REPRESENTATIVE (authorized signature) PHONE

X

PPG NAME

PPG #

TODAY'S DATE

MEMBER COMPLETED ONE OF THE FOLLOWING PROGRAMS:

K Early Prenatal K Breastfeeding K Baby Care Basics K Childbirth Preparation

DATE OF CLASS

1 By

providing your email address, you authorize Health Net to send you pertinent information regarding the Get Fit! program and/or your medical plan.

Please note: This gift program is available in California only. To receive your gift cards you or your PPG must mail or FAX this form to the address below. If you attended a class outside of your PPG, please send a class registration receipt from that facility.

Get Fit! c/o Health Net (S. Garcia) 155 Grand Ave., 3rd Floor Oakland, CA 94612 FAX: 510-287-4694

CA32767 (9/06) Health Net of California, Inc. is a subsidiary of Health Net, Inc. Health Net® is a registered service mark of Health Net, Inc. All rights reserved.

UC Get Fit! Wellness Incentive Program Evaluation

After concluding this program, please complete the following evaluation. Male _____ Female _____ Date of Birth ____________ 1. Did you complete the online health risk questionnaire (HRQ)? ____ Yes ____ No 2. How easy was it to take the HRQ and/or participate in the wellness programs? ____ Easy to get started ____ Moderately easy; needed help and instructions to get started ____ Difficult to locate 3. How did you learn about the Get Fit! program? ____ Health Net mailings and communications ____ Campus activities and communications ____ Office of the President communications Congratulations and thank you for participating in Get Fit!, a Health Net sponsored program for the University of California. We encourage you to stay well and reap the rewards of good health. 4. Did the incentive component motivate you to participate in the program? ____ Yes ____ No 5. In general, what kind of incentives would motivate you to participate? Check all that apply. ____ Gift certificates or gift cards ____ Funds donated to charity ____ Points (redeemed for goods) ____ Points (redeemed for frequent flyer miles) ____ Raffle/Sweepstakes/Contest

UC Get Fit! Wellness Incentive Program

Congratulations for completing the Get Fit! Program. Fill out the information below and send your completed Get Fit! forms, fitness tracking tool(s) and survey to: Get Fit!; c/o Health Net (S. Garcia); 155 Grand Avenue, 3rd floor; Oakland, California 94612. If you provide an email address, we will send your eGift Card via email. Please write legibly. Name _______________________________________________ Subscriber ID # _________________________________ Address _____________________________________________________________________________________________ City _________________________________________________________________ State ________ ZIP _____________ Phone ______________________________________________________________________________________________ Email _______________________________________________________________________________________________

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