Forms You Might Need

We want to make it easy for you to find important forms, so we’ve placed them here. You can select the item you need help with and link to the correct form.

If you have questions or need more information about any of these forms, please give us a call.

BlueCare Customer Service: 1-800-468-9698
TennCareSelect Customer Service: 1-800-263-5479

I need help with:

I need to: Form to use:

Report different treatment by a health care provider or caregiver

Discrimination Complaint - English

Queja De Discriminación  - en Espanol 

Find out how I can see my Personal Health Information (PHI) and how it will be used and shared

Notice of Privacy Practices

Name a personal representative

Authorization for Use and Disclosure of Health Information

Limit the sharing and use of my PHI

Request for Limited Use and Disclosure of My Health Records

Get a list of who has requested and received my PHI

Request for a List of Disclosures of My Health Information

Allow BlueCare Tennessee to use my PHI or share it with a third party

Authorization to Release Information

Make sure a third party can no longer receive my PHI

Revocation of Authorization to Disclose Health Information

Ask to have my health information sent to me in a different way or place

Confidential Communication Request

Look at my health records on file

Request to Look at My Health Records

Make a change to my medical records on file

Request to Change My Health Records

File a complaint about TennCare's privacy practices

Documentation of Privacy Complaint

Appealing a denial, reduction or delay of benefits

See page 112 of your member handbook

Change the Primary Care Provider (PCP) listed on my Member ID card

PCP Change Request

Plan for my treatment and care when I can no longer make those decisions myself

Advance Care Plan

Change my address
For the fastest service, call the TennCare Connect at (855) 259-0701, 8 a.m. – 8 p.m. Eastern Time. Or you can print out the form to mail.

Member Address Change Form

Document my wishes in case of a mental health crisis

Declaration of Mental Health Treatment Form

Print a form to take to my first prenatal visit with the doctor

Prenatal Incentive Form (English)

Prenatal Incentive Form (Español)

Print a form to take to my new mom checkup with the doctor

Postpartum Incentive Form (English)

Postpartum Incentive Form (Español)