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.

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.