Tenncare Request For Release PDF Form - FormsPal

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.

Question	Answer
Form Name	Tenncare Request For Release Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	31
Avg. time to fill out	6 min 31 sec
Other names	tenncare release request, tenncare release estate, tenncare estate recovery, how long does it take to get a tenncare release

12

Form Preview Example

REQUEST FOR RELEASE FROM THE BUREAU OF TENNCARE

As required by T.C.A. §71-5-116(c)(2)

PLEASE ALLOW 10 WORK DAYS FOR RESPONSE

SUBMIT BY FAX OR U.S. MAIL. NO DUPLICATES PLEASE!

TO: Manager of Estate Recovery Unit

	FAX (615) 532-7509	Bureau of TennCare
	FAX (615) 532-7509	Estate Recovery Unit
		Estate Recovery Unit
		729 Church Street
		Nashville, TN 37247-6501

Decedent’s Information

______________________________ ___________________				___________________________________
<Decedent’s Full Legal Name>	<Social Security Number>			<Date of Birth, m/d/yr>		<Date of Death, m/d/yr>
	Decedent’s Spouse Information
_________________________________	___________________			___________________________________
<Decedent’s Spouse’s Full Legal Name>	<Social Security Number>			<Date of Birth, m/d/yr>		<Date of Death, m/d/yr>
Surviving Minor Child(ren) or Disabled Dependent(s) Information
________________________________		__________________			_______________
<Full Legal Name>			<Social Security Number>		<Date of Birth>
________________________________		__________________			_______________
<Full Legal Name>			<Social Security Number>		<Date of Birth>
________________________________		__________________			_______________
<Full Legal Name>			<Social Security Number>		<Date of Birth>

________________________	______________________________				________________________
Probate Case Number		County				Date Opened
__________________________________________			__________________________________________
<Signature>					<Printed Name>
Relationship to decedent’s estate:	Personal Representative/Executor of Estate
	Attorney for Estate

Address:

Telephone Number: (	) ___________________	Fax Number: (	)_________________________
TC-0042 (Rev. 11-02)			RDA 2041

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 request for release 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 estate

In the Date, Opened County, Printed, Name Probate, Case, Number Signature, and Fax, Number area, put down your information.

Filling in tenncare release estate part 2

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.

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