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If you choose to register or decline, we will not tell anyone outside the election commission about your

choice or where you applied. We will only use this for registration purposes.

You can’t vote until you get your voter registration card. If you do not have the card in three weeks,

check with the Election Commission.

The County Election Commission will see if you are able to register to vote. This is not done by DHS

or the TennCare Bureau.

If you mail your application to your county election commission, you must vote in person the first time

you vote.

We will mail you a “Mail-In Application for Voter Registration” form within 30 days if you are telling

us by phone or internet about:

o An address change

o An application

o A re-application

o A re-certification

o A review

If the deadline to register is less than 30 days away, we will mail the form to you within 5 days or the next work

day if we can.

HIPAA:

The federal HIPAA law says we must keep facts about your health private. It also says we must give you this

notice. Here are the rules that we must follow to keep the facts about your health private. These rules can

change. If important changes are made, we will tell you.

In order to determine your eligibility for Families First, DHS may share your private health information

with:

Some employees of the Department who need it to decide if you can get Families First.

DHS may also share your private health information with the federal Department of Health and Human

Services because they provide oversight of the Families First program.

With your prior written consent, DHS may share your private health information with any other person

or entity, such as your health care providers, an attorney, and/or members of your family.

If you are not able to provide prior written consent, DHS may share your private health information

with:

An authorized representative – who will also have the right to provide written consent for release of

your private health information to other individuals and entities;

A family member or others involved in your health care. You may ask us not to tell them your

information. We will agree if we can. If you are a minor child or in an emergency, we may not be able

to agree.

Without any prior consent, DHS may also share your private health information:

With a health oversight agency or law enforcement as required by law for purposes of investigating

fraud allegations related to receipt of program benefits;

With any other individual or entity, including law enforcement and other government agencies, when

allowed by law or when required to do so by a court order;

With another individual or entity for purposes of research, as permitted by law.

RIGHTS ABOUT YOUR HEALTH INFORMATION

You have the right to:

See your health records, except where limited by law.

Get copies of your health records, except where limited by law.

Talk to us about how we use and share your health information.

Ask us to change health information that you think is wrong. You must ask us to change it in writing and

tell us why. We may not be able to change it. If we can’t change it, we will tell you why.

Form Hs-0169 - Family Assistance Application - Tennessee Department Of Human Services Page 6

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