Miscellaneous Provider Forms
- Address Change - Group/Entity (pdf, 27kb)
- Adjustment/Void Form (pdf, 2,157kb)
- Certification of Medical Necessity for Abortion (English) (pdf, 100kb)
- Certification of Medical Necessity for Abortion (Spanish) (pdf, 425kb)
- Disclosure Form For a Provider Entities (pdf, 8ikb)
- Hysterectomy Acknowledgment Form (pdf, 105kb)
- Medicaid Reclamation Claim Provider Refund Request Form (pdf, 34kb)
- Name Change for Group/Entity
- National Provider Identification (NPI)
- Provider Termination Form (pdf, 64kb)
- Remittance Advice Request Form (pdf, 17kb)
- Sterilization Consent Form Instrctions (pdf, 115kb)
- Sterilization Consent Form
- Sterilization Consent Form (Español)
- Substitute W-9 (pdf, 11kb)
- How to Report Third Party Liability (TPL) Insurance Updates to the Bureau of TennCare (pdf, 109kb)
- Third Party Liability (TPL) Update Request Fax Form (pdf, 518kb)
