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Title VI Discrimination Complaint Form

  1. You do not need to sign this form if you are submitting form digitally through the Cabarrus Health Alliance website. Submission through the website represents your signature.
  2. If the person who has been discriminated against is a minor, please complete parent information below:
  3. The remaining information on this form is optional. Completing these following questions are voluntary and will not affect Cabarrus Health Alliance decision in the review of your complaint.
  4. Do you need special accommodations for us to communicate with you about this complaint? (Check all that apply)
  5. If we cannot reach you directly, is there someone we can contact to help us reach you?
  6. Have you filed your complaint anywhere else? If so, please provide the following.
  7. To submit your complaint with Cabarrus Health Alliance, please type or print, sign, and return completed complaint form to the Cabarrus Health Alliance at the address below:

    Cabarrus Health Alliance

    Melissa Blovsky
    Compliance Officer

    300 Mooresville Rd
    Kannapolis, NC 28081 
    Contact Number (704)-920-1343
    Fax: (704) 933-3329 
    TDD: (800) 537-7697 
    Email: melissa.blovsky@cabarrushealth.org

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  9. This field is not part of the form submission.