Room-to-Breathe Asthma Program

Asthma can't be cured, but with proper care it can be controlled. The Room-to-Breathe asthma program can significantly improve children’s control of their asthma, decreasing admissions to the hospital, emergency room visits and frequency of aggravations. This care management program includes asthma supplies and education for Carolina Complete Health members ages 18 and under.

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 a minimum of 14 days for review and processing of your request. If you need immediate support, please call 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

Member Name * As it appears on your Medicaid ID card if Member

Member ID Number (found on your Carolina Complete Health Member ID Card) * Enter Member ID of member aged 18 or under

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 *

To get started with the Room to Breathe Asthma Program, please select all that apply from the list below. * I would like to speak to a Carolina Complete Health Care Manager about my child’s asthma. I would like to schedule a home environmental assessment with a Carolina Complete Health Care Manager to help identify asthma triggers for my child. I would like to talk to a Carolina Complete Health Care Manager about support that may be available for my child including hypoallergenic bedding/sheets, dehumidifier, cleaning supplies, etc.

If your child is 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).