Fillable REQUEST FOR RELEASE Person Submitting Request 310 GREAT (Jefferson County, Tennessee)

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REQUEST FOR RELEASE Person Submitting Request 310 GREAT (Jefferson County, Tennessee)

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U.S.A. forms for Jefferson County, Tennessee

BROWSE JEFFERSON COUNTY, TENNESSEE (TN) FORMS

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Final Form: RFR 2020-2
RFR PROCESSING UNIT
310 GREAT CIRCLE ROAD, 3W
NASHVILLE, TN 37243
Phone: (615) 741-0636, Fax (615) 413-1941
Email: RFR.TENNCARE@TN.GOV
REQUEST FOR RELEASE
Deceased
Person’s Name:
First
Middle
Last
Person Submitting Request
Name:
Address:
Street Address
City
State
Phone:
Email:
Information About Probate Court Case
Has a probate court case been filed? If yes, check the box and fill out the rest of this section.
County the case was filed in:
Date the case was filed:
Court Case Number:
Request that TennCare Waive or Delay Recovery of Claim
Are you are asking TennCare to waive (drop) or delay recovery of its claim? If yes, check any boxes that apply. See the
instructions at the bottom of this page for the other documents you must send us with this page.
Deceased is survived by a child under 21
Deceased had long-term care insurance
Deceased is survived by a child that the Social Security Administration determined to be blind or
permanently and total disabled.
Deceased is survived by a spouse
Surviving Spouse’s SSN
Surviving spouse’s full name
Information about Trust
Is the deceased the beneficiary of a trust? If yes, check this box and list the trustee’s contract information
below
Name:
Address:
Street Address
City
State
Phone:
Email:
INSTRUCTIONS:
1. Email, mail or fax this completed page and the deceased’s death certificate, to the RFR Processing Unit. The email,
address, and fax number is at the top of this page.
2. If the deceased is survived by a child under 21, send a copy of the child’s birth certificate with this page.
3. If the deceased had long-term care insurance, send a copy of the policy documents with this page.
4. If the deceased was survived by a blind or disabled child, send a copy of the child’s birth certificate and the
determination/award letter from the Social Security Administration with this page.
5. If the deceased is the beneficiary of a trust, send us a copy of the trust with this page.
Final Form: RFR 2020-2
• 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
Final Form: RFR 2020-2
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 that’s available.
Spanish: Español
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 866-389-8444 (TRS:711).
Kurdish: 

866-389-8444 (TRS:711). 
Arabic: اﻌﻟ ةيبر
866-389-8444 :ﻗ  .ﻣﻧ ﻟ ﺗﻣﻓ ﻐﻟﻟ ﺳﻣﻟﻋ ﺧﻣ ﻌﻟ ﻐﻟﻟ ﻟﻛﺗﺗ  :ﺣﻟﻣ
(TRS: 711)ﻛﺑﻟ ﻟ ﻫ ﺗ ﻗ
Chinese: 繁體中文
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電866-389-8444
(TRS: 711).
Vietnamese: Tiếng Việt
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số
866-389-8444 (TRS:711).
Korean: 한국어
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
866-389-8444 (TRS:711).번으로 전화해 주십시오.
French: Français
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 866-389-8444 (TRS:711).
Amharic: አማርኛ
ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 866-389-8444 (መስማት
ለተሳናቸው:TRS:711 ).
Gujarati:



, :

 

866-389-8444 (TRS:711) .
Laotian: 
:


 , 



, 


, 


. 866-389-8444
(TRS:711).
German: Deutsch
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 866-389-
8444 (TRS:711).
Tagalog: Tagalog
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa
866-389-8444 (TRS:711).
Hindi: ह दी

:    
  

   
866-389-8444
(TRS:711) .   
Serbo-Croatian: Srpsko-hrvatski
OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno.
Nazovite 866-389-8444 (TRS- Telefon za osobe sa oštećenim govorom ili sluhom: 711 ).
Russian: Русский
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
Звоните 866-389-8444 (телетайп: TRS:711 ).
Nepali: नेपाली
 

:   
       
    

866-389-8444
(: TRS:711
Persian: 
هجوت
(TRS:711) 866-389-8444 
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REQUEST FOR RELEASE Person Submitting Request 310 GREAT (Jefferson County, Tennessee)

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Completed 8 April 2021

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