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.
 

Certification of Dependency Form
Complete this form and mail it to TRH to verify your dependent's eligibility. It is important to verify that your dependents between the ages of 18 and 23 continue to be eligible on your coverage. You should notify TRH immediately of any change of status for your dependents.


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
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 25 months and under)
If applying for coverage, this medical request form contains the medical information required for children age 25 months and under.
 

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 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
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 Benefit Exclusion Rider
This form is for you to complete when submitting a request for reconsideration of a benefit exclusion rider that has been placed on you or any dependents. Please use one form per rider being reviewed.
 

Request for Reconsideration of Declined Coverage
This form is for you to complete when submitting a request for reconsideration of declined coverage for you or any dependents.
 

Request for Reconsideration of Rate
This form is for you to complete when submitting a request for reconsideration of your rate for coverage.
 

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 3 years 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.