Neurological Support Sensory Kit

Carolina Complete Health members who are diagnosed with a developmental, intellectual or neurodegenerative disorder.

Eligibility

Carolina Complete Health members have been diagnosed with a neurological disorder and have completed their annual Care Needs Screening. One kit per member per plan year (April 1 - March 31).

NEUROLOGICAL SUPPORT SENSORY KIT FORM

Have you completed your annual Care Needs Screening? Yes No

You must have a current Care Needs Screening on file to request this Value-added Service.

If you 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 * Carriers do NOT deliver to P.O. Boxes or APO/FPO Addresses. All addresses must be submitted in English. An order that is addressed incorrectly may result in the shipment being sent back to our facility causing extended delays or order cancellation.

City *

Zip Code * Must be 5 digits

Member Phone Number *

Member Email Address *