Room-to-Breathe Asthma Program

The Room-to-Breathe asthma program was developed to help members control of their asthma by providing education and resources. Eligible members (all ages) can receive up to $150 in support items to help address environmental triggers. To be eligible for the Room-to-Breathe program, members must be diagnosed with asthma by their Primary Care Provider (PCP) and enrolled in Care Management.

To get this Value-Added service, please fill out the form below.

Eligibility Statement: Eligibility requirements apply based on Care Management team health risk assessment. You must be a current Carolina Complete Health member to receive this Value-Added Service.

Note: Please allow at least 4-6 weeks for review and processing of your request. Room-to-Breathe Asthma items cannot be sent to P.O. boxes, and a responsible party must sign for the delivery of the package. For assistance, please contact us at
1-833-552-3876 (TTY 711). This Value-Added Service requires the recipient or a responsible party to sign for the delivery of their package.

ROOM TO BREATHE REQUEST FORM

Do you have an asthma diagnosis provided by your Primary Care Physician (PCP)? Yes No

You are unable to submit a Room-to-Breathe Asthma request because you do not have an asthma diagnosis from your Primary Care Physician.

If you need assistance, please contact your Care Manager or call Member Services at 1-833-552-3876 (TTY 711).

Member Name * As it appears on your Carolina Complete Health Member ID card

Member ID Number * As it appears on your Carolina Complete Health Member ID card

Member Date of Birth *

Member Address (Must match address on file with Carolina Complete Health) Room-to-Breathe Asthma Program items cannot be sent to a Post Office (P.O.) box. Please enter a physical mailing address. Any requests submitted with a P.O. Box listed will not be processed.

Name of Person filling out this form (if different from Member)

Phone Number *

Email Address *

If you or your child are experiencing an asthma-related medical emergency, please dial 911.

This Value-Added Service requires the recipient or a responsible party to sign for the delivery of their package. * I agree

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).