TC 0136: TennCare Request for Release Form

Enter the Deceased Person's Name: First, Middle and Last.

Under Person Submitting Request, fill in Name, Street Address, City, State, Zip Code, Phone and Email.

Information About Probate Court Case: has a probate court case been filed? If yes, check the box and fill out the rest of this section. County the case was filed in: Date Filed: Case Number:

Request that Tenncare Waive or Delay Recovery of Claim: are you asking Tenncare to waive (drop) or delay recovery of its claim? If yes, check any boxes that apply.

Deceased is survived by a child under 21. If the deceased is survived by a child under 21, also send a copy of the child's birth certificate.

Deceased had long-term care insurance. If the deceased had long-term care insurance, also send a copy of the policy documents.

Deceased is survived by a child that the Social Security Administration has determined to be blind or permanently and totally disabled. If the deceased was survived by a blind or disabled child, also send a copy of the child's birth certificate and the determination/award letter from the Social Security Administration.

Deceased is survived by a spouse. Surviving spouse's full name: Surviving Spouse's Social Security Number:

Information about Trust: is the deceased the beneficiary of a trust with a Medicaid payback provision? If yes, check this box and list the trustee's contact information. Please provide a copy of the trust.

Trustee's contact information: Name, Street Address, City, State, Zip Code, Phone and Email.

If the deceased is the beneficiary of a trust with a Medicaid payback plan, also send a copy of the trust.

Email, mail or fax this completed page and a legible copy of the deceased's death certificate with Social Security Number unredacted to the RFR Processing Unit. RFR Processing Unit, 310 Great Circle Road, 3W, Nashville, TN 37243. Phone: (615) 741-0636, Fax (615) 413-1941, Email: RFR.TENNCARE@TN.GOV.