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.

QuestionAnswer
Form NameTenncare Request For Release Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namestenncare release for estate, how long does it take to get a tenncare release, how to get a tenncare release, tenncare request for release of estate recovery claim

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

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

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