Forms

Forms

Bank Draft Authorization Form
If you need to change your bank information for your monthly premium payment, complete this form, attach a voided check and mail both to TRH.

 

Change Form 
This form allows you to make changes to your current coverage.


Grievance Form
Use this form to submit a formal request for a review of an adverse benefit determination.


Health Coverage Claim Form
(for services rendered on or after July 1, 2015) Most providers will file health care claims for you. However, should you need to file a claim, please complete this form.


Health Coverage Claim Form
(for services rendered on or before June 30, 2015) Most providers will file health care claims for you. However, should you need to file a claim, please complete this form.


Medical Request Form (age 0-2 months)
If applying for coverage, this medical request form contains the medical information required for children age 2 months and under.


Medical Request Form (age 2-25 months)
If applying for coverage, this medical request form contains the medical information required for children age 2 months to 25 months.



Medical Request Form (age 40 and older)
If applying for coverage, this medical request form contains the medical information required for individuals age 40 and older.
 

Medicare Supplement Prescription Drug Claim Form
(for services rendered on or after July 1, 2015) To file prescription drug claims, complete this form and attach your prescriptions receipt or a print-out of your prescriptions signed by your pharmacist.
 

Medicare Supplement Subscriber Health Care Claim Form 
(for services rendered on or after July 1, 2015) Use the following form when your provider does not file a claim. This information applies to any doctor, hospital, clinic or provider of health care. 


Notice to Applicant Regarding Replacment of Medicare Supplement Insurance or Medicare Advantage (Medicare Replacement Form)
If you have a current Medicare Supplement or Medicare Advantage insurance and are replacing it with a TRH plan, please complete this form.


Membership Application and Agreement
Complete this form to apply for membership to the Tennessee Farm Bureau. Membership is necessary to be eligible for coverage by TRH Health Plans.


Newborn Waiver Form
If you are applying for coverage and are currently an expectant parent, completion of a Newborn Waiver form will be required before the application can be processed. The Newborn Waiver form establishes that the newborn child, upon delivery, will not have automatic coverage. A new application to add the newborn child will be required and the child will be underwritten. After the application process is complete, the newborn child will be added to the coverage on the next available effective date.


Notice of Privacy Practices
This notice explains your rights to privacy and how TRH may use your protected health care information.


Other Insurance Form
You should always keep TRH informed of other insurance that you and your dependents may have as TRH coverage contains a coordination of benefits provision. Complete this form and mail it to TRH when you obtain other insurance.


Patient Protection and Affordable Care Act Acknowledgment Form
This form is an acknowledgment that the TRH health plan you are applying for is not covered by the federal Patient Protection and Affordable Care Act. This form may not be required for the plan in which you are applying.


Personal Representative Designation Form
Your completion of this form allows you to designate someone as your personal representative on your TRH health care coverage.


Prescription Drug Claim Form for Mail Order
This form is for you to complete in order to mail order prescriptions.



Prescription Drug Claim Form for Mail Order Instructions
Intructions on how to set up your mail order prescriptions.


Prescription Drug Claim Form U65
(for services rendered on or after July 1, 2015) To file prescription drug claims, complete this form and attach your prescription receipt or a print-out of your prescriptions signed by your pharmacist.


Prescription Drug Claim Form
(for services rendered on or before June 30, 2015) To file prescription drug claims, complete this form and attach your prescription receipt or a print-out of your prescriptions signed by your pharmacist.


Request for Reconsideration of Tobacco Rate

This form is for you to complete and submit if you (or anyone on your contract) have not used tobacco in over 24 months and would like to send a request to change to a non-tobacco rate.


Under 65 Grandfathered Application
This application is for members that have TRH Grandfathered coverage. Grandfathered coverage is that which went into effect before 03/23/2010. 

 

Medicare Supplements Insured by TRH Health Insurance Company, Columbia, TN.
TRHH-POST-POLA-FL14-174; TRHH-POST-POLB-FL14-175; TRHH-POST-POLC-FL14-176; TRHH-POST-POLD-FL14-177; 
TRHH-POST-POLF-FL14-178; TRHH-POST-POLG-FL14-179; TRHH-POST-POLM-FL14-180; TRHH-POST-POLAN-FL14-181
Not connected with or endorsed by the U.S. or state government. This is a solicitation of insurance. A representative of TRH Health Insurance Company may contact you. Benefits not provided for expenses incurred while coverage under the policy is not in force, expenses payable by Medicare, non- Medicare eligible expenses or any Medicare deductible or copayment/coinsurance or other expenses not covered under the policy.

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