Fillable THIRD PARTY LIABILITY UPDATE FAX REQUEST (State of Tennessee)

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THIRD PARTY LIABILITY UPDATE FAX REQUEST (State of Tennessee)

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The THIRD PARTY LIABILITY UPDATE FAX REQUEST (State of Tennessee) form is 1 page long and contains:

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  • 33 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of Tennessee

BROWSE STATE OF TENNESSEE (TN) FORMS

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THIS IS AN ONLINE FILLABLE FORM 1) Type directly into this form 2) Print 3) Fax
(Limited to 500
Characters)
REMARKS:
Credible Coverage Letter Attached?
NoYes
Group Number:
Policy Number:
Insurance Carriers Name:
This Insurance Carrier Coverage Needs to be Added - EFFECTIVE DATE:
This Insurance Carrier Coverage Needs to be Terminated - TERM DATE:
Medicaid Recipient ID#:SSN:
DOB (Date of Birth):Recipient Name:
Contact Number:
Contact Name:
Provider Phone:
Provider Address:
Provider Name:
Number of Pages:
TO:
TPL Coordinator
Fax Number:
(615) 734-5113
Today's Date:
THIRD PARTY LIABILITY UPDATE FAX REQUEST
DIVISION OF TENNCARE
310 Great Circle Road
NASHVILLE, TN 37243
DEPARTMENT OF FINANCE AND ADMINISTRATION
STATE OF TENNESSEE
OR
*All information requested on this form is required. Incomplete forms will not be processed.
Policy Holder:
SSN:
Name:
If this is a Medicare Policy, select the appropriate Medicare Policy type; otherwise select Not Applicable.
Not ApplicableSupplemental PlanAdvantage Plan
Relationship to Policy Holder:
DependentSpouseSelf
TN
TC-0142 (rev 4-15) RDA: 2038
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THIRD PARTY LIABILITY UPDATE FAX REQUEST (State of Tennessee)

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Completed 29 March 2021

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