Forms
To request a printable form, complete the Print Request Form. Select your entity and provide the requested information before submitting the form.
- Enrollment Change Application – Active Members and COBRA 2027
- TennCare Notice
- Corrections and Clarifications Form
- Administrative Error Form - Higher Education, Local Education & Local Government
- Agency ACH Form
- Individual Authorization Agreement for Preauthorized Payment (for Retirees and COBRA only)
- Request for Claims/Enrollment Data
- To request large claims data for premium bids, email benefits.privacy@tn.gov
- Insurance Cancel Request Application 2027
- Certification of Eligibility for Dependents by Valid Placement Order Form
- Certification of Eligibility for Dependents with Expired Placement Order Form