School Supplies

At Carolina Complete Health, we believe child education is an important part of overall health and wellness. That's why we offer all members enrolled in grades Pre-Kindergarten through 12^th grade basic school supplies per plan year.

Eligibility Statement: Eligibility requirements apply. You must be a current Carolina Complete Health member to receive this Value Added Service. One Voucher per child per plan year. Grades Pre-K to 12. Must be at least 3 years old. Must complete separate form for each child.

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

PRE-K-12th GRADE SCHOOL SUPPLIES FORM

Member Name * As it appears on your Carolina Complete Health Member ID card / Member must be enrolled in PreK - 12th grade.

Name of person filling out this form (If not member, must be a Parent or Legal Guardian of the member)

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

Member Birthday * Enter birthday of member enrolled in PreK - 12th grade.

Member Address (Must match address on file with Carolina Complete Health) * School Supplies 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) *

Pick as supply grade package Grades Pre-K – 2, Supplies include: crayons, ruler, glue stick, and pencils Grades 3 – 7, Supplies include: markers, ruler, pencils, pens, folders, and paper Grades 8 -12, Supplies include: highlighters, pens, pencils, folders, and paper

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).