Get Tn Tenncare Authorization Of Representative Organization Form 2024-2025

Filling out the TN TennCare Authorization Of Representative Organization Form online is a straightforward process that allows you to designate an organization to act on your behalf regarding TennCare matters. This guide provides step-by-step instructions to help you complete the form efficiently and accurately.

Follow the steps to fill out the form correctly

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the applicant or member's information. Fill in their name (last, first, middle initial), phone number, ID number (which can be their Social Security number or Member ID), date of birth, address, city, state, zip code, and email address.
3. In the responsibilities of the representative organization section, select the options that your authorized representative will have. These options include signing applications, submitting renewal forms, receiving communications from TennCare, and acting on your behalf for other matters.
4. If you selected options related to medical information disclosure, ensure that you understand what information will be shared with the representative organization as per your selections on the form.
5. For authorization termination or changes, follow the provided instructions to indicate your understanding of the process for changing or ending the responsibilities of your chosen representative organization.
6. Both the representative organization's employee and the applicant/member must sign the form. Ensure that you enter the organization name, address, type, authorized employee's name, title, email, phone number, and the signature date.
7. The applicant/member must also sign the form, acknowledging the responsibilities and agreements outlined. Select the duration for authorized representation and ensure all signatures are provided.
8. After completing the form, review the information for accuracy, and then save your changes, download a copy, and print or share the form as needed before mailing or faxing pages 2 and 3 to the specified address.

Complete your documents online and empower your TennCare experience.