Community Care Plan ("CCP") wants to make sure that our members get the best health care. Answering these questions will help the member’s primary care physician and our nurses know what the member’s needs are.

This information is kept private. Answers do not affect member benefits in any way.

If you need help filling out this form, call us at 1-866-899-4828 TTY/TDD 1-855-655-5303 Monday to Friday from 8:00am to 7:00pm.