Tenncare Request For Release Form PDF Details

The Tenncare Request for Release Form is a document used to authorize the release of protected health information (PHI) to a third party. The form must be completed and signed by the individual authorized to make such requests, and must include the name of the individual or organization who will receive the PHI, as well as the specific information that will be released. Completed forms should be submitted to Tenncare in accordance with their procedures.

Here is the details concerning the form you were seeking to fill out. It will tell you the time you'll need to fill out tenncare request for release form, exactly what fields you will have to fill in, and so on.

Form NameTenncare Request For Release Form
Form Length3 pages
Fillable fields21
Avg. time to fill out5 min 1 sec
Other nameshow to get a tenncare release, tenncare release form fillable form, tenncare release on property, tenncare release

Form Preview Example

RFR PROCESSING UNIT 310 GREAT CIRCLE ROAD, 3W NASHVILLE, TN 37243 Phone: (615) 741-0636, Fax (615) 413-1941










Person Submitting Request



Street Address


Suite #






Zip Code


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 the case was filed:

Court Case Number:





Request that TennCare Waive or Delay Recovery of Claim

Are you are asking TennCare to waive (drop) or delay recovery of its claim? If yes, check any boxes that apply. See the instructions at the bottom of this page for the other documents you must send us with this page.

Deceased is survived by a child under 21

Deceased had long-term care insurance

Deceased is survived by a child that the Social Security Administration determined to be blind or permanently and total disabled.

Deceased is survived by a spouse

Surviving spouse’s full name

Surviving Spouse’s SSN

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 below. Please provide a copy of the trust.



Street Address


Suite #






Zip Code



1.Email, mail or fax this completed page and the deceased’s death certificate to the RFR Processing Unit.

2.If the deceased is survived by a child under 21, also send us a copy of the child’s birth certificate.

3.If the deceased had long-term care insurance, also send us a copy of the policy documents with this page.

4.If the deceased was survived by a blind or disabled child, also send us a copy of the child’s birth certificate and the determination/award letter from the Social Security Administration.

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

Form: RFR 2021-2

Do you need help talking with us or reading what we send you?

Do you have a disability and need help getting care or taking part in one of our programs or services?

Or do you have more questions about your health care?

Call us for free at 866-389-8444. We can connect you with the free help or service you need. (For TRS call: 711)

We obey federal and state civil rights laws. We do not treat people in a different way because of their race, color, birth place, language, age, disability, religion, or sex. Do you think we did not help you or you were treated differently because of your race, color, birth place, language, age, disability, religion, or sex? You can file a complaint by mail, by email, or by phone. Here are two places where you can file a complaint:






U.S. Department of Health & Human





Services, Office for Civil Rights

310 Great Circle Road, Floor 3W


200 Independence Ave SW, Rm 509F, HHH

Nashville, Tennessee 37243



Bldg., Washington, DC 20201








Phone: 1-800-368-1019

Phone: 1-855-857-1673 (TRS 711)



(TDD): 1-800-537-7697






You can get a complaint form online at:

You can get a complaint form online at:










Or you can file a complaint online at:













Form: RFR 2021-2

Do you need free help with this letter?

If you speak a language other than English, help in your language is available for free. This page tells you how to get help

in a language other than English. It also tells you about other help that’s available.


ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

Llame al 866-389-8444 (TRS:711).




ەب یدنەویەپ .ەتسەدرەب ۆت ۆب ،ییاڕۆخەب ،نامز یتەمرای یناکەیرازوگتەمزخ ،تیەکەد ەسەق یدروک ینامز ەب رەگەئ :یراداگائ

866-389-8444 (TRS:711)..ەکب






:ربﻗم لصتا .ﻣاجﻧا ﻟك ﺗﻣوﻓةر اﻐﻟﻟةیو اﺳﻣﻟاﻋةد ﺧدﻣتا اﻌﻟةیبر اﻐﻟﻟة ﻟﻛﺗﺗم اذا :ﺣﻟﻣةظو

(TRS: 711)اﻛﺑﻟم و اﻟمص ﻫاﺗف رﻗم






(TRS: 711).



Tiếng Việt

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số

866-389-8444 (TRS:711).





주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 866-389-8444 (TRS:711).번으로 전화해 주십시오.

French: Français

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 866-389-8444 (TRS:711).


ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 866-389-8444 (መስማት ለተሳናቸው:TRS:711 ).


સચના:ુ જો તમેગજરાતીુ બોલતા હો, તો નન:શલ્કુ ભાષા સહાય સેવાઓ તમારા માટેઉપલબ્ધ છે.ફોન કરો

866-389-8444 (TRS:711) .

Laotian: ພາສາລາວ

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ້າພາສາ ລາວ, ການບໍ ິລການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບ່ໍ ເສັຽຄ່າ, ແມ່ນມີ ພ້ອມໃຫ້ທ່ານ. ໂທຣ 866-389-8444 (TRS:711).


ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 866-389- 8444 (TRS:711).


PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 866-389-8444 (TRS:711).


ह िंदी

ध्यान दें: यदद आप द िंदीबोलते ैंतो आपकेललए मफ्तु मेंभाषा स ायता सेवाएिंउपलब्ध ैं।866-389-8444

(TRS:711) . पर कॉल करें।

Serbo-Croatian: Srpsko-hrvatski

OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno.

Nazovite 866-389-8444 (TRS- Telefon za osobe sa oštećenim govorom ili sluhom: 711 ).


ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.

Звоните 866-389-8444 (телетайп: TRS:711 ).

Nepali: नेपाली

ध्यान ददनुोस:्तपार्इंलेनेपालीबोल्नुुन्छ भनेतपार्इंकोननम्तत भाषा स ायता सेवा रूननिःशल्कु रूपमा उपलब्ध छ । फोन गनोस ्866-389-8444

(दिदिवार्इ: TRS:711 ।


اب .دشاب یم مهارف امش یارب ناگیار تروصب ینابز تلایهست ،دینک یم وگتفگ یسراف نابز ەب رگا :هجوت

.دیریگب سامت (TRS:711) 866-389-8444

Form: RFR 2021-2

How to Edit Tenncare Request For Release Form Online for Free

Not many tasks are quicker than managing forms through the PDF editor. There isn't much you should do to edit the tenncare release for estate document - simply adopt these measures in the next order:

Step 1: Search for the button "Get Form Here" on the following website and next, click it.

Step 2: Now you are going to be on your form edit page. You can include, adjust, highlight, check, cross, add or erase areas or text.

The PDF template you wish to complete will consist of the next segments:

part 1 to completing tenncare release request

In the Are you are asking TennCare to, Deceased is survived by a child, Deceased had longterm care, Deceased is survived by a child, Deceased is survived by a spouse, Surviving Spouses SSN, Surviving spouses full name, Is the deceased the beneficiary of, Information about Trust, Address, Street Address, Suite, City, State, and Zip Code area, put down your information.

Filling in tenncare release request part 2

Note the expected details when you're on the You can get a complaint form, httpwwwtngovassetsentitiestenncare, You can get a complaint form, httpwwwhhsgovocrofficefileindexhtml, and Or you can file a complaint online area.

step 3 to finishing tenncare release request

Step 3: In case you are done, select the "Done" button to export the PDF form.

Step 4: Get a minimum of two or three copies of the file to stay away from different potential complications.

Watch Tenncare Request For Release Form Video Instruction

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