Request for New Tutor

Parents/guardians of members have the right to request a different tutor for their child for any reason. To request a new tutor, please fill out the Request for New Tutor form below or contact Member Services at 1-833-552-3876 (TTY 711).

Member Name (as it appears on your Medicaid ID card) *

Member ID Number (found on your Carolina Complete Health Member ID Card) *

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

City *

State *

Zip Code *

Name of person filling out this form (Must be Parent or Legal Guardian of Member)

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

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

Name of Current Tutor *

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).