| Request For Release From Bureau Of TennCare As Required By TCA Section 71-5-116(c)(2) Form. This is a Tennessee form and can be used in General Probate Court Shelby Local County . |
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REQUEST FOR RELEASE FROM THE BUREAU OF TENNCARE As required by T.C.A. ยง71-5-116(c)(2) PLEASE ALLOW 10 WORK DAYS FOR RESPONSE SUBMIT BY FAX OR U.S. MAIL. NO DUPLICATES PLEASE! TO: Manager of Estate Recovery Unit FAX (615) 532-7509 Bureau of TennCare Estate Recovery Unit 729 Church Street Nashville, TN 37247-6501 Decedent's Information ______________________________ ___________________ ___________________________________ Decedent's Spouse Information _________________________________ ___________________ ___________________________________ Surviving Minor Child(ren) or Disabled Dependent(s) Information ________________________________ __________________ _______________ ________________________________ __________________ _______________ ________________________________ __________________ _______________ ________________________ Probate Case Number ______________________________ County ________________________ Date Opened __________________________________________ __________________________________________ Relationship to decedent's estate: Address: Personal Representative/Executor of Estate Attorney for Estate Telephone Number: ( TC-0042 (Rev. 11-02) ) ___________________ Fax Number: ( ) _________________________ RDA 2041 American LegalNet, Inc. www.USCourtForms.com
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