Forms
The number one reason providers visit our website is to find a form, so we have them all in one place and organized by line of business to make it easier for you.
Patient Notifications
BlueCare/TennCareSelect
Appeal Forms
- Provider Reconsideration Form
- Provider Appeal Form
- Provider Appeal – Expedited
- Value Based Payment Appeal Form
- Value Based Reconsideration Form
Patient Authorizations – Forms you send us to approve care for a patient
- Ventilator Weaning and Sub-Acute Tracheal Suctioning Request
- Bariatric Surgery Authorization Request Form
- Complex Rehabilitation Technology DME Authorization Request
- Durable Medical Equipment Request Form
- Initial Member/Caregiver Training Checklist
- Private Duty Nursing/Home Health Plan of Care
- Private Duty Nursing Home Plan of Care Agreement
- Recertification Member/Caregiver Training Checklist
- Provider-Administered Specialty Pharmacy Products
- Prior Authorization Request Form
- Behavioral Health Patient Authorization Forms
- Behavioral Health Out of Network Request Form
- Mental Health Inpatient Request Form
- Mental Health Outpatient Request Form
- Psychiatric Residential Treatment Request Form
- Psychological Testing Form
- Provider Discharge Form
- Referral for Applied Behavioral Analysis (ABA)
- Assessment, Initiation and Continuation Request Form for Applied Behavior Analysis
- Request Out of Network Benefits
- Skilled Nursing Facility and Inpatient Rehabilitation Fax Form
- Therapy Request Form
- Transplant Fax Form
Patient Administration
- Adult Preventive Health Flow Sheet
- Authorization to Release Confidential Information
- Behavioral Health Adverse Occurrence
- Certification of Medical Necessity for Abortion
- Certification of Medical Necessity for Abortion (Spanish)
- Death of a Member Notification
- Discharge Information Form
- Home Health Critical Incident Form
- Hysterectomy Acknowledgement Form
- Hysterectomy Acknowledgement Form (Spanish)
- PCP Change Request
- Release of Health Information
- Best Practice Network PCP Medical Record Update
- Sterilization Consent (English)
- Sterilization Consent (Spanish version)
- Sterilization Consent Form FAQ
- TennCare Behavioral Health Adverse Occurrence Report
- Abortion Medical Necessity Certification (English)
- Abortion Medical Necessity Certification (Spanish)
- Abortion Medical Necessity Form Instructions
- Sterilization Consent Form Instructions
Office Administration
- Claim Status Check Form
- Community Outreach Referral Fax Form
- Overpayment Information
- Home Health Missed Visit Form
- Provider/Vendor Subcontracting Form
- Provider/Vendor Subcontracting Exhibit
School-Based Services Forms
- Notice of Access to Information - English
- Notice of Access to Information - Spanish
- Notice of Access to Information - Arabic
- Consent to Access Information - English
- Consent to Access Information - Spanish
- Consent to Access Information - Arabic
CHOICES
- LTSS Removal of Services Form
- Guidance for Providers on Nursing Facility Changes of Ownership
- CHOICES Minor Home Modifications General Bidder Tool
- CHOICES Provider Standard Assessment and Documentation Review Form (for site visits)
- CHOICES Ramp Bid Tool
- Physician Discontinuation of Services Order Form
- Statewide HCBS Waiver Provider Requirements – Standards Assessment and Documentation Review (for site visits)
Employment and Community First CHOICES
Reportable Event Management
CoverKids
- Abortion Medical Necessity Certification (English)
- Abortion Medical Necessity Certification (Spanish)
- Abortion Medical Necessity Form Instructions
- Request Out of Network Benefits
- Durable Medical Equipment Request Form
- Hysterectomy Acknowledgment Form (English)
- Hysterectomy Acknowledgment Form (Spanish)
- Prior Authorization Request Form
- Skilled Nursing Facility/Inpatient Rehabilitation Authorization Request
- Sterilization Consent Form Instructions
- Sterilization Consent Form (English)
- Sterilization Consent Form (Spanish)