Eligibility Appeal Form

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Having problems getting TennCare, CHOICES, or QMB/SLMB?
Use these pages only to file a
Need help filing an eligibility appeal?
• Call 1-855-259-0701 for free.
.
TennCare Eligibility Appeal
Fill out both pages. These are facts we must have to work your appeal. If you don’t tell us all the facts
we need, we may not be able to decide your appeal. You may not get a fair hearing. Need help understanding
what facts we need? Call us for free at 1-855-259-0701. If you call, we can also take your appeal by phone.
1. Who is the person that wants to appeal?
Full name ______________________________________________ Date of birth _____/_______/_________
Social Security Number ________-_________-________
Current mailing address_____________________________________________________________________
City____________________________________________________State_____________Zip Code________
What language do you speak best?
English
Spanish
Kurdish
Somali
Arabic
Vietnamese
Bosnian
Other__________
If Spanish, do you need us to send your letters in Spanish?
Yes
No
2. Are there other people in your household who have this same problem?
Give us their names, dates of birth, and social security numbers.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
3. Who filled out this form?
If not the person that wants to appeal, give us your contact information:
Name_____________________________________________________________________________________
Address___________________________________________________________________________________
Phone_________________________________________Fax_________________________________________
Are you a:
a parent or relative
an advocate or friend
an attorney
a health care provider
Guardian or Conservator
Other_________________________
For us to speak to this person about the appeal, we may need an OK in writing. To give us an OK in writing,
you can use our HIPAA Permission to Release Records.
Go to
https://tn.gov/assets/entities/tenncare/attachments/releaserecord.pdf
to print it and send it to us with these
pages.
Keep reading. There is 1 more page for you to fill out.
Rev: 26May15

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