Miscellaneous Provider Forms

• Adjustment/Void Form
  
• Optical Examination Waiver Form
  
• Provider’s Expedited Appeal Certificate (This certificate does not pertain to appeals for eligibility for TennCare.)
• TennCare Provider Refund Request form
• Third Party Liability (TPL) Update Request Fax Form
• Nursing Facility Capital Update Form
• Nursing Facility Cost and Utilization Form for Annual Assessment
• Emergency Medical Services Revenue and Quality Measure Report

Abortion, Sterilization, Hysterectomy Forms (ASH)

• Certification of Medical Necessity for Abortion (English)
  • Instructions for Certification of Medical Necessity for Abortion Form
• Certification of Medical Necessity for Abortion (Spanish)
• Hysterectomy Acknowledgment Form (English)
• Hysterectomy Acknowledgment Form (Spanish)
• Sterilization Consent Form Instructions
• Sterilization Consent Form (English)
• Sterilization Consent Form (Español)
• Sterilization Consent Form FAQ