Care Grant

Carolina Complete Health offers a once per lifetime care grant of up to $250 for eligible members. The Care Grant can assist members with non-medical factors that affect health outcomes. The once per lifetime up to $250 Care Grant (per eligible member) can be used to support the following:

Housing rental deposit, utility payments or moving expenses
Post hospitalization home-delivered meals, with pre-approval
Natural healing services to include chiropractor, acupuncture, massage or tribal healing

Eligibility Statement: Eligibility requirements apply. You must be a current Carolina Complete Health member to receive this Value-Added Service. One care grant per member per plan lifetime. Member must be enrolled in Care Management.

Note: Please allow at least 4-6 weeks for review and processing of your request.

CARE GRANT REQUEST FORM

Are you enrolled in Care Management? * Yes No

You are unable to submit a Care Grant request because you are not currently enrolled in Care Management.

If you have any questions or need assistance please contact 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) * Value-Added Service 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.

City *

Zip Code *

Phone Number (Must be Parent or Legal Guardian of Member) *

Email Address (Must be Parent or Legal Guardian of Member) *

I have read the eligibility for this Value-Added Service and understand that eligibility requirements apply. * I agree If eligible, a care manager will reach out to you at the provided email address or phone number.

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 *

City *

Zip Code *

Phone Number (Must be Parent or Legal Guardian of Member) *

Email Address (Must be Parent or Legal Guardian of Member) *

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 *

City *

Zip Code *

Phone Number (Must be Parent or Legal Guardian of Member) *

Email Address (Must be Parent or Legal Guardian of Member) *

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 *

City *

Zip Code *

Phone Number (Must be Parent or Legal Guardian of Member) *

Email Address (Must be Parent or Legal Guardian of Member) *

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).