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2. Full Name
3. Phone Number
5. Address1
7. City
8. State
9. Zip
11. Date you believe discrimination occured.
    Date you believe discrimination occured.
13. Describe briefly what happened. How and why do you believe that you have been discriminated against? Please be as specific as possible.
15. 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.
17. If the person who has been discriminated against is a minor, please complete parent information below:
19. Name of parent or legal guardian
21. 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.
23. Do you need special accommodations for us to communicate with you about this complaint? (Check all that apply)

    1. Braille
    2. Large Print
    3. Electronic mail
    4. Sign language interpreter

    1. TDD
    2. Foreign language interpreter
    3. Other
25. If we cannot reach you directly, is there someone we can contact to help us reach you?
27. Contact Name
28. Phone Number
30. Have you filed your complaint anywhere else? If so, please provide the following.
32. Person/Agency/Organization/Court Name(s)
34. Date Filed
    Date Filed
35. Case Number(s) if known
37. 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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39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field