To name someone to handle your TennCare business for you, download the TennCare authorized representative form from the TennCare Forms and Agreements page, complete pages 2 and 3, have both you and your representative sign, and send it to TennCare Connect at P.O. Box 305240, Nashville, TN 37230-5240, or by fax to 855-315-0669.1TennCare. Member / Applicant2TennCare. TennCare Forms and Agreements The form is free.
Pick the Right Version Before You Download
TennCare publishes two versions. The individual form is for naming a specific person — a family member, friend, or attorney. The organization form is for naming a group, such as a legal aid office or social services agency.2TennCare. TennCare Forms and Agreements Most people need the individual version. Both are downloadable PDFs.
What to Put on the Form
The PDF is three pages. Page 1 is instructions. Only pages 2 and 3 get filled in and returned.
- Your full legal name, Social Security Number, and TennCare ID number. Your TennCare ID is printed on your TennCare card and on any letters the agency has sent you.
- Your representative’s full name, physical address, and phone number.
- Signatures from both of you. TennCare will not process a form that is missing either signature, because the representative is accepting specific responsibilities when they sign.3Tennessee Department of Finance and Administration. PRIV 030 – Authorized Representatives in Agency Interactions
The form covers eligibility matters, applications, and ongoing communications with TennCare.
Signing When You Can’t Be in the Same Room
TennCare accepts electronic signatures, handwritten signatures sent by fax, and even signatures recorded over the phone. You and your representative can complete the form by phone if the applicant is homebound or living in a care facility.3Tennessee Department of Finance and Administration. PRIV 030 – Authorized Representatives in Agency Interactions
If You Already Have Power of Attorney or Guardianship
A power of attorney, guardianship or conservatorship order, or custody order is also accepted as proof of your authority to act for someone with TennCare.3Tennessee Department of Finance and Administration. PRIV 030 – Authorized Representatives in Agency Interactions Attach a copy of the court order or legal document when you submit the form so TennCare can confirm your authority without sending follow-up requests.
One boundary worth knowing: a TennCare authorized representative designation covers only your interactions with TennCare — eligibility, applications, renewals, and related communications. It does not grant the broader authority that a power of attorney can give over finances, property, or healthcare decisions. If you need someone to handle Medicaid asset planning, such as setting up trusts or transferring property to help you qualify, this form alone will not give them that power. That takes a separate power of attorney drafted with those provisions.
How to Submit the Completed Form
Send pages 2 and 3 to TennCare Connect:
- Mail: TennCare Connect, P.O. Box 305240, Nashville, TN 37230-5240
- Fax: 855-315-0669
Both match what TennCare publishes on its Member/Applicant page.1TennCare. Member / Applicant The TennCare Connect portal at tenncareconnect.tn.gov and its mobile app also let you upload photos of documents, which may work as a digital submission channel.4Google Play. TennCare Connect – Apps on Google Play If you fax, keep the confirmation page. No filing fee applies.
TennCare does not publish a processing time for this designation specifically. For context, standard eligibility applications can take up to 45 days and long-term care applications up to 90 days.5TennCare. TennCare Frequently Asked Questions A representative designation is simpler, but build in some lead time. If a renewal deadline is bearing down while your form is still in the pipeline, call TennCare Connect at 855-259-0701 to flag the urgency.
What Your Representative Can Do Once Named
Federal rules give an authorized representative four powers: signing an application for you, completing and submitting your renewal, providing required documents and evidence, and acting for you in all other matters with the agency.6eCFR. 42 CFR 435.923 – Authorized Representatives That fourth category covers responding to information requests, appealing decisions, and talking with TennCare staff about your case.
Your representative also receives copies of your TennCare notices and other official correspondence.6eCFR. 42 CFR 435.923 – Authorized Representatives That matters most at renewal time, when a missed deadline can end your coverage. The representative must keep your information confidential.7GovInfo. 42 CFR 435.923 – Authorized Representatives
How Long It Lasts and How to End It
The designation stays active until one of four things happens: the authorization reaches a time limit or condition written into the form; you revoke it; the representative resigns; or the underlying legal authority changes, such as the applicant’s death or a court order being revoked.3Tennessee Department of Finance and Administration. PRIV 030 – Authorized Representatives in Agency Interactions
You can give TennCare notice of any of those changes electronically, by phone, or in writing. Ending the relationship does not require a new form; a phone call is enough. To swap in a different representative, you would submit a new form naming the replacement.
Choose Someone Reliable
Anything your representative tells TennCare is treated as if you said it yourself. Knowingly providing false information on a Medicaid application or renewal can trigger penalties under the federal False Claims Act, and the law’s definition of “knowing” reaches past deliberate fraud to include reckless disregard for whether information is true.8U.S. Department of Health and Human Services Office of Inspector General. Fraud and Abuse Laws Your representative does not need to be a lawyer. A family member or close friend is fine. Pick someone organized enough to meet TennCare’s deadlines and careful enough to get your household and income details right.