TennCare Change of Address Reporting Form - Tennessee
STATE OF TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION DIVISION OF HEALTH CARE FINANCE AND ADMINISTRATION
BUREAU OF TENNCARE
Internal Use Only SNAP? Yes No DHS Case #: ___________
TennCare Change of Address Reporting Form
TennCare sends important information to you in the mail. To be sure you get it, TennCare must have your current address (where you live now).
If you haven't given TennCare your current address, please call 1-855-259-0701. It's a free call. Or, you can fill out and sign the form below ? and send it to TennCare.
Be sure to check for mail from TennCare. Open any mail from TennCare and follow the instructions. If you have questions about mail from TennCare, call 1-855-259-0701.
Your Name (First, Middle, Last):
Your SSN (if you have one):
Your Date of Birth:
Your Telephone #:
New Mailing Address
Apt. # City, State
ZIP
Tell us who in your family has TennCare and lives at this new address:
Name (First, Middle, Last):
Date of Birth:
SSN:
Name (First, Middle, Last):
Date of Birth:
SSN:
Name (First, Middle, Last):
Date of Birth:
SSN:
Name (First, Middle, Last):
Date of Birth:
SSN:
Name (First, Middle, Last):
Date of Birth:
SSN:
Please change my mailing address to the new mailing address above. TennCare should send all mail for me and my family to this new mailing address.
X __________________________________________
Signature of Enrollee (or parent of child enrollee)
___________________
Date
Mail this page to:
TennCare, P.O. Box 305240 Nashville, TN 37230-5240 or fax it to: 1-855-315-0669.
TC-0161 Dev: 2Dec2015
RDA 2047
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