Please Allow 20 Business Days for Response As Required by TCA 71-5-116[c)[2) STATE OF TENNESSEE BUREAU OF TENNCARE TPL Division 310 Great Circle Road, 4th Floor Si usted necesita esta forma en Español, por favor llame al 1-866-389-8444 NASHVILLE, TENNESSEE 37243 Toll Free: 866-389-8444 • FAX: 615- 532-7509 REQUEST FOR RELEASE OF ESTATE RECOVERY COST CLAIM A COPY OF THE DEATH CERTIFICATE MUST ACCOMPANY THIS REQUEST _________________ _______________ _______/_______/______ Probate Case No. Date Probate Opened County of Probate Decedent’s Information: _________________________ _______________________ Decedent’s Last Name Decedent’s First Name Decedent’s Middle Name or Maiden Name [Married] [Divorced] [ Single] [Never Married] _________________________ _______________________ Decedent’s Social Security No. ____________________________________ Decedent’s Marital Status ________________ ____________________ Decedent’s Date of Birth Decedent’s Date of Death YOU MUST PROVIDE INFORMATION REGARDING THE DECEDENT’S SPOUSE IF APPLICABLE: Is the Decedent’s Spouse Pre-Deceased Yes No _____________ Spouse’s Date of Death if Pre-Deceased _______________ _______________________ ______________________ Spouse First Name Spouse Last Name [mm-dd-yyyyy] ___________________ ______________________ Spouse Middle Name or Maiden Name Spouse Date of Birth ______________________ _______________________________________________________________ Spouse Social Security No. The person completing this document is the: [_______]Executor [_______]Representative [_______]Legal Counsel for the Estate. Name: _____________________________________________ Address:_____________________________________________ Phone:_(_____)____________________________ _________________________________ _________________________________ 1. ________________________________________ Signature of Person Completing This Document ARE YOU REQUESTING AN EXEMPTION DUE TO SURVIVING SPOUSE. IF YOU ARE, YOU MUST PROVIDE THE FOLLOWING INFORMATION AND/OR DOCUMENTATION IN ADDITION TO WHAT IS INDICATED ABOVE: _________A copy of your marriage license. 2. ARE YOU REQUESTING AN EXEMPTION DUE TO A CHILD 18 YEARS OF AGE ? _________ A copy of the birth certificate of the minor child. 3. ARE YOU REQUESTING AN EXEMPTION FOR A DISABLED CHILD? IF YOU ARE, YOU MUST PROVIDE: __________A copy of the Social Security Administration determination of permanent total disability prior to the age 18. __________A copy of the birth certificate of the disabled child. * THIS DOCUMENT WILL NOT BE PROCESSED WITHOUT ALL INFORMATION REQUESTED & SIGNATURE TC-0087 American LegalNet, Inc. www.USCourtForms.com Notice: CONFIDENTIAL INFORMATION REGARDING A TENNCARE RECIPIENT AND/OR DECEASED TENNCARE RECIPIENT WILL NOT BE RELEASED WITHOUT PRIOR AUTHORIZATION FROM THE EXECUTOR/EXECUTRIX, ESTATE REPRESENTATIVE and/or LEGAL COUNSEL FOR THE ESTATE. INSTRUCTIONS 1. PROVIDE ALL REQUESTED INFORMATION AND SIGN THE RELEASE REQUEST. You must provide information about the deceased person and the deceased person’s spouse even though the spouse may have pre-deceased the decedent and the executor or estate representative must sign the request.. 2. PROVIDE ALL REQUESTED DOCUMENTATION IF YOU ARE REQUESTING AN EXEMPTION TO RECOVERY. 3. PROVIDE A COPY OF THE DECEDENT’S DEATH CERTIFICATE OR OTHER DOCUMENTATION AS INDICATED ON THE RELEASE. 4. PROVIDE AN ADDRESS FOR RETURN OF THE RELEASE FORM. THE RELEASE FORM WILL NOT BE FAXED. 5. THE FORM MAY BE RETURNED WITHOUT A COVER LETTER BUT YOU MUST PROVIDE A RETURN ADDRESS. 6. IF YOU HAVE QUESTIONS REGARDING THE COMPLETION OF THE REQUEST FOR RELEASE FORM PLEASE CALL [866) 389-84444 OR [615) 532-7085. INFORMATION YOU SHOULD BE AWARE OF WHO IS SUBJECT TO RECOVERY? ANY PERSON OVER 55 YEARS OF AGE FOR WHOM TENNCARE HAS PAID FOR NURSING FACILITY SERVICES OR CARE RECEIVED FROM HOME & COMMUNITY BASED SERVICES. IF THE ESTATE IS NOT BEING PROBATED, YOU DO NOT HAVE TO PROVIDE THE PROBATE COURT INFORMATION BUT YOU MUST OBTAIN A RELEASE OF TENNCARE’S CLAIM PRIOR TO DISBURSEMENT OF FUNDS AND/OR ASSETS. HOW MUCH WILL THE PERSON’S ESTATE HAVE TO PAY BACK TO TENNCARE? THE ACTUAL VALUE OF ALL FUNDS EXPENDED BY TENNCARE FOR THE PERSON’S COST OF SERVICES IN A NURSING FACILITY AND/OR HOME & COMMUNITY BASED SERVICES. WHAT ARE THE EXEMPTIONS? IF THERE IS A SURVIVING SPOUSE,TENNCARE WILL NOT RECOVER FROM THE ESTATE UNTIL THE TIME OF THE SURVIVING SPOUSE’S DEATH IF: 1. THE SURVIVING SPOUSE REQUESTS AN EXEMPTION; AND 2. THE SURVIVING SPOUSE PROVIDES DOCUMENATION OF PROOF OF MARRIAGE, . IF THERE IS A MINOR CHILD UNDER THE AGE OF 18, TENNCARE WILL NOT RECOVER FROM THE ESTATE UNTIL THE MINOR CHILD REACHES THE AGE 18 IF: 1. THE CHILD OR THE CHILD’S REPRESENTATIVE REQUESTS AN EXEMPTION TO RECOVERY; AND 2. THE CHILD OR THE CHILD’S REPRESENTATIVE PROVIDES A COPY OF THE CHILD’S BIRTH CERTIFICATE AS PROOF OF RELATIONSHIP. IF THERE IS A DISABLED CHILD WHO BECAME DISABLED PRIOR TO THE AGE OF 18, TENNCARE WILL NOT RECOVER FROM THE ESTATE UNTIL THE DEATH OF THE DISABLED CHILD IF: 1. THE DISABLED CHILD OR THE DISABLED CHILD’S REPRESENTATIVE REQUESTS AN EXEMPTION; AND 2. THE DISABLED CHILD OR THE DISABLED CHILD’S REPRESENTATIVE PROVIDES A COPY OF THE SOCIAL SECURITY DISABILITY DETERMINATION PROVING DISABILITY AND ONSET PRIOR TO THE AGE OF 18; AND 3. THE DISABLED CHILD OR THE DISABLED CHILD’S REPRESENTATIVE PROVIDES A COPY OF A BIRTH CERTIFICATE PROVING RELATIONSHIP. WHAT HAPPENS WHEN THE SURVIVING SPOUSE, MINOR CHILD OR DISABLED CHILD DIES? AT THE TIME OF THE DEATH OF THE SURVIVING SPOUSE, TENNCARE WILL RECOVER FROM THE ESTATE ASSETS THE VALUE OF ALL EXPENSES PAID UP TO THE TOTAL AMOUNT EXPENDED FOR CARE IN A NURSING FACILITY OR HOME & COMMUNITY BASED SERVICES. HOW MAY I OBTAIN A RELEASE OF TENNCARE’S INTEREST IN AN ESTATE? 1. COMPLETE THE REQUEST FOR RELEASE FORM; AND 2. PROVIDE ALL DOCUMENTATION REQUESTED; AND 3. IF THE ESTATE IS SUBJECT TO RECOVERY, YOU MUST PAY TENNCARE’S CLAIM TO OBTAIN A RELEASE. American LegalNet, Inc. www.USCourtForms.com