Request for TennCare Release

STATE OF TENNESSEE BUREAU OF TENNCARE227ESTATE RECOVERY ----: TENNCARE REQUEST FOR RELEASE OF ESTATE RECOVERY CLAIM I NFORMATION ABOUT THE DECEASED PERSON Full name Date of birth Date of death Social Security number Marital status widow/widower divorced married single Did the deceased receive TennCare CHOICES (home and community-based or nursing facility care)? YES NO Do not know I NFORMATION ABOUT THE SPOUSE OF THE DECEASED PERSON (complete even if spouse is already deceased and also attach copy of deceased spouse222s death certificate) Full name Date of birth Date of death Social Security number I NFORMATION ABOUT P ROBATE C OURT C ASE Has a Probate Court case been opened for the deceased? YES NO If yes, what date was the case filed? In what County was the case filed? In what State was the case filed? What is the court case number? I NFORMATION ABOUT THE PERSON COMPLETING THIS FORM Full name Relationship to deceased Address Phone number Email Signature Date Deferral/exception request on page 2 (OVER) Instructions: American LegalNet, Inc. www.FormsWorkFlow.com D EFERRAL /E XCEPTION REQUEST Are you requesting a release or deferral/exception for any of the following reasons? (Check ALL that apply) Decedent never received benefits Surviving spouse Surviving son or daughter under age 21 urviving son or daughter who is blind or permanently and totally disabled (you must provide a copy of the Social Security Administration determination of permanent total disability AND a copy of each child222s birth certificate) L ONG - T ERM C ARE I NSURANCE For TennCare enrollees: Did the decedent have long-term care insurance? Yes No Not sure Do you need help talking with us or reading what we send you? Do you have a disability and need help getting care or taking part in one of our programs or services? Or do you have more questions about your health care? Call us for free at 866-389-8444. We can connect you with the free help or service you need. (For TRS call: 711) We obey federal and state civil rights laws. We do not treat people in a different way because of their race, color, birth place, language, age, disability, religion, or sex. Do you think we did not help you or you were treated differently because of your race, color, birth place, language, age, disability, religion, or sex? You can file a complaint by mail, by email, or by phone. Here are two places where you can file a complaint: TennCare Office of Civil Rights Compliance 310 Great Circle Road, Floor 3W Nashville, Tennessee 37243 Email: HCFA.Fairtreatment@tn.gov Phone: 1-855-857-1673 (TRS 711) You can get a complaint form online at: http://www.tn.gov/assets/entities/tenncare/ attachments complaintform.pdf U.S. Department of Health & Human Services, Office for Civil Rights 200 Independence Ave SW, Rm 509F, HHH Bldg., Washington, DC 20201 Phone: 1-800-368-1019 (TDD): 1-800-537-7697 You can get a complaint form online at: http://www.hhs.gov/ocr/office/file/index.html Or you can file a complaint online at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf American LegalNet, Inc. www.FormsWorkFlow.com Do you need free help with this letter? If you speak a language other than English, help in your language is available for free. This page tells you how to get help in a language other than English. It also tells you about other help that222s available. Spanish: Espa361ol - - Kurdish: - - Arabic: -- : . : (TRS: 711) Chinese: -- Vietnamese: Ti ng Vi t tr - - Korean: : , . - - . French: Fran347ais - - Amharic: : - - ( : TRS:711 ). Gujarati: : , : . - - Laotian: : , , , . -- German: Deutsch - - Tagalog: Tagalog - - Hindi: -- American LegalNet, Inc. www.FormsWorkFlow.com Serbo - Croatian: Srpsko - hrvatski - - - - Russian: - - Nepali: -- Persian : : . ) - - . American LegalNet, Inc. www.FormsWorkFlow.com