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

• Behavioral Health Provider Initiated Notice Adverse Action

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
• Provider Administered Specialty Medication Step Therapy Guide
• 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 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

• LTSS Removal of Services Form

Reportable Event Management

• DIDD Reportable Event Form
• Provider Final Investigation Report Template

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)