Member Forms

  • You+Blue

To find the form you need, click the sentences below.

If you have questions or need more information on any of these forms, please call us. Remember certain items about you must be verified before we can talk about your medical information.

BlueCare Customer Service: 1-800-468-9698

TennCareSelect Customer Service: 1-800-263-5479

I want to authorize release of my information to a third party.

To authorize the release of your information to a third party, the attached form should be completed.
Authorization Form

I want to revoke the release of my information to a third party that had been previously authorized.

To remove the authorization to release your information to a third party, the attached form should be completed.
Revocation of Authorization Form

I need to give instructions on how I want to be treated by doctors and facilities when I can no longer make those decisions myself.

Complete the Advance Care Plan form in order to state intentions or wishes such as burial arrangements, funeral plans, treatment options and decisions.

I don’t agree with how a claim or request has been processed or denied. I want to file an appeal.

Review this webpage: Member Appeals and complete the TennCare Medical Appeal form.

I need to change who is listed as my primary care doctor (PCP).

Complete the PCP Change form (Updated 3/2016) found in your member handbook.

I have been treated unfairly by my doctor or caregiver.

We do not allow unfair treatment in TennCare. State and Federal laws protect you from unfair treatment No one can treat you in a different way because of your:

  • • Race
  • • Disability
  • • Religion
  • • Sex

  • • Birthplace
  • • Color
  • • Age
  • • Language
You may contact any of the places listed on the form below. You also have the right to file a complaint. By law, no one can get back at you for filing a complaint.
Unfair Treatment Complaint
Discrimination Complaint Form and Agreement to Release Information - English
Formulario de Queja de Discriminación y Acuerdo para divulgar información - Español

How will my medical information be used and shared? How can I see my information?

This notice explains how medical information about you may be used and shared. Please carefully read the following:
BlueCare Tennessee HIPAA member rights - Notice of Privacy Practices

Information about my health care needs to be sent to me in a different way or at a different place.

To change the way we send information to you about your health, use this form. You will be asked to tell us why you are asking for the change.
Amendment of Health Records Request Form

I need to make a change to my health information on file.

You have the right to make a written request to change your health plan information.
Use this form to request that we change your health information. *This request requires approval

Complete the Request to Change My Health Records form in order to request a change to a health record. You also need to give the reason for the change.

I need to be allowed to look at my health records.

Use this form to ask to view your health records.
Access to Records Request

I need to ask for a list of disclosures of my health information on file.

Use this form to ask for a list of the times your health information has been requested and shared (disclosed). This will include times BlueCare Tennessee or our business associates asked for it in the past six years.
Request for a List of Disclosure of My Health Information
In response to this request, you will receive an complete listing of disclosures through the form Disclosure of Enrollee Protected Health Information (PHI).

I want to make sure my personal health information (PHI) is given to someone other than me

Use this form to give us permission to use your health information for the reason stated. It can also be used to give another person permission to share your health information to us.
Authorization Disclosure of Health Information

I need to make an official complaint about BlueCare Tennessee’s privacy practices.

Use this form to make a complaint about our privacy practices.
Documentation of Privacy Complaint

I need to make a change to my address on file.

Use this form to request that we change the address we have on file. It is very important to keep your correct address on file with us so that important health information is received where you live.

Complete the Change of Address form in order to request. The completed form will be mailed to the Tennessee Health Connection address listed at the bottom of the form.

I need to limit who can look at my health records.

Request for Limited Use Disclosure of Health Records



Page updated on 8/21/2014