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Get Tenncare Attestation Form 2020-2026
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How to fill out the Tenncare Attestation Form online
Navigating the Tenncare Attestation Form online can feel overwhelming. This guide provides a step-by-step approach to assist you in accurately filling out the form, ensuring all necessary information is included and submitted properly.
Follow the steps to complete the Tenncare Attestation Form online:
- Press the ‘Get Form’ button to retrieve the Tenncare Attestation Form and view it in the designated online editor.
- Begin with the member information section. Fill in the last name, first name, ID number, and date of birth of the member. Ensure accuracy, as this information is crucial for verification.
- Proceed to the authorized prescriber information section. Here, enter the prescriber's last name, first name, NPI number, DEA number, phone number, and fax number.
- Indicate whether the prescriber is a Tenncare provider with a Medicaid ID by selecting ‘Yes’ or ‘No’. Repeat this for the question regarding whether the prescriber holds a single-patient contract for this patient.
- In the specialty section, briefly describe the prescriber’s specialty.
- Next, provide an attestation statement by filling in your name and the patient’s name. Describe the potential health risks to the patient without specified medications and affirm that no alternatives can be used.
- List the requested drugs in the provided table. Include the drug name, strength and frequency, quantity, and relevant diagnosis. Check the appropriate box for whether each drug is for acute or maintenance use.
- Finalize your certification by signing the form, affirming that the information provided is accurate and complete. Include the date of signing.
- Review all entered information for accuracy. Once verified, you can save your changes, download the completed form, and prepare it for submission.
- Submit the completed form via fax to 1-866-434-5523 to reach the TennCare Pharmacy Program, ensuring all documentation is attached as necessary.
Start filling out your Tenncare Attestation Form online today for efficient processing.
To apply for healthcare in Tennessee, visit the state’s healthcare enrollment website or contact your local Department of Human Services office. You will need to gather necessary documents, such as income information and identification. Completing the Tenncare Attestation Form accurately is a crucial step in this process, ensuring that your application reflects your eligibility.
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