REQUEST FOR RELEASE FROM THE BUREAU OF TENNCARE As required by T.C.A. §71-5-116(c)(2) PLEASE ALLOW 10 WORK DAYS FOR RESPONSE SUBMIT BY FAX OR U.S. MAIL. NO DUPLICATES PLEASE! TO: Manager of Estate Recovery Unit Bureau of TennCare Estate Recovery Unit 729 Church Street Nashville, TN 37247-6501 FAX (615) 532-7509 Decedent’s Information ______________________________ ___________________ ___________________________________ Decedent’s Spouse Information _________________________________ ___________________ ___________________________________ Surviving Minor Child(ren) or Disabled Dependent(s) Information ________________________________ __________________ ________________________________ __________________ ________________________________ __________________ ________________________ Probate Case Number ______________________________ County __________________________________________ _______________ _______________ ________________________ Date Opened __________________________________________ Relationship to decedent’s estate: _______________ Personal Representative/Executor of Estate Attorney for Estate Address: Telephone Number: ( TC-0042 (Rev. 11-02) ) ___________________ Fax Number: ( ) _________________________ RDA 2041 American LegalNet, Inc. www.USCourtForms.com