Forms

• Enrollment Change Application – Active Members and COBRA (2025)
  
  • Enrollment Change Application – Active Members and COBRA (2024)
• TennCare Notice
• Corrections and Clarifications Form
• Administrative Error Form - Higher Education, Local Education & Local Government 
• Fax Document Separator
• 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 
• Dependent Verification Fax Transmittal Sheet
• Certification of Eligibility for Dependents by Valid Placement Order Form
• Certification of Eligibility for Dependents with Expired Placement Order Form
• Cigna DHMO Onsite Dentistry - Jet Dental

Security Authorization Forms

• Edison Benefits User Security Authorization Form - State
• Instructions for Edison Benefits User Security Authorization Form – State
• VIDEO GUIDE: Edison Benefits User Security Authorization Form – State 
• Edison Benefits User Security Authorization Form - Higher Education, Local Education & Local Government
• Instructions for Edison Benefits User Security Authorization Form – Higher Education, Local Education & Local Government
• VIDEO GUIDE: Edison Benefits User Security Authorization Form – Higher Education, Local Education & Local Government