Member Complaint and Grievances Form

If you are unhappy with the quality of care or service you received, the way you were treated by your doctor, problems getting care, or billing issues you can file a grievance. A grievance and a complaint are the same thing. Complete this form if you would like to file a grievance about Carolina Complete Health (CCH), your doctor, or your health services.

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Member Information

First Name *

Last Name *

Medicaid ID # *

Phone Number *

Email *

Name of Parent / Legal Guardian (if applicable)

Complaint (Grievance) Details

Date of Issue *

Date Issue reported to health plan: *

Enter a brief description of the issue: * (Include dates and names of the doctor/facility/vendor, authorization/claim number, service/medication):

How can CCH resolve your issue? *

This form will send your message to Carolina Complete Health as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Carolina Complete Health through email, you accept the risks associated thereof. Carolina Complete Health does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your protected health information (PHI), please send us a message through the Secure Member Portal or Provider Portal, or you can call us at 1-833-552-3876 (TTY 711) to speak directly to a member service representative.

If you need assistance filling out this form, please call Member Services at 1-833-552-3876 (TTY 711).