Printer-Friendly 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 - 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.

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.

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.

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.

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.

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

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.

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.