Member Complaint / Grievance Form

We want to help you resolve your complaint to your satisfaction as quickly as possible. Please mail us anything that may help us understand your complaint, along with your completed form to: Community Eye Care (CEC), Attn: Complaint & Grievance, 4944 Parkway Plaza Blvd, Suite 200, Charlotte, NC 28217. After receiving this form, you should hear back from us within 30 calendar days. If you have questions, please call Customer Service at 888.254.4290 or visit www.cecvision.com.

All fields are required unless noted.

Your Information

First Name

Last Name

Member ID

Mailing Address/ PO Box

City

State

Zip Code

Phone

Employer Name

Patient Name

Complaint/Grievance Information

Description of the Complaint / Grievance

How can we help resolve this?

Date

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Member Complaint / Grievance Form

Your Information

Complaint/Grievance Information

Doctor Information