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Administrative Manual Section: General Administrative Procedures and Compliance Policy Manual Number: 200.005 Chapter: Confidentiality & Privacy February 1, 2018 Division of TennCare 3 The Authorized Representative forms are available at: Authorization of Representative - Individual and Authorization of Representative - Organization. There are separate forms for entities and individuals being designated as representatives, and the correct one must be submitted in each case. Once an individual is verbally designated as a representative or appropriate document or completed form is received, discuss the individual’s TennCare Medicaid only with the person(s) being authorized to receive the information. To authorize individuals or organizations to receive healthcare information, but not make decisions on behalf of an applicant/enrollee, a Authorization to Release Member Information Form is required when it is not designated on the application. Offer to mail or fax the requesting party or individual a blank form that the individual can complete, execute and mail or fax to Tennessee Health Connection (TNHC). Once the completed form is received, discuss the individual’s TennCare Medicaid only with the person(s) listed on the form as being authorized to receive the information. If TennCare receives a signed authorization form that is different from the form provided, forward the form to the TennCare OGC, Privacy Office for approval at Privacy.TennCare@tn.gov or via fax to 615-734-5289. In order to be valid, the authorization form must be completely filled out. The authorization form must also contain an expiration date. Always check the expiration date on the form to ensure that the authorization has not expired. If approval is not provided by the Privacy Office, the authorization form will not be considered acceptable to authorize the individual to represent the applicant/enrollee. 4. Application by Department Employees and their Relatives A TennCare employee must notify his supervisor as soon as practicable if and when the employee, the employee’s family member or person with whom the employee maintains a close personal relationship applies for benefits. a. Definitions Family Member: A family member is defined as one of the following i. Relationships by blood: parent, child, grandparent, grandchild, brother, sister, uncle, aunt, nephew, niece, first cousin; and ii. Relationships by marriage: husband, wife, step-parent, stepchild, brother-in-law, sister- in-law, father-in-law, mother-in-law, son-in-law, daughter-in-law, half-brother, half- sister, uncle, aunt, nephew, niece, spouse of any of the above.