HCFA Authorized Representative Preview on Page 1

HCFA Authorized Representative 2026

The document is a TennCare Authorization of Representative Organization Form, which allows individuals to designate an organization to act on their behalf regarding TennCare eligibility and medical benefits. It outlines the submission process, legal basis for representation, responsibilities of the representative organization, and options for terminating or changing authorization. The form must be completed and signed by both the applicant and the representative organization to be valid.

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Click ‘Get Form’ to open the HCFA Authorized Representative form in the editor.
Begin by filling out the Applicant/Member Information section. Enter the name, phone number, ID number, date of birth, address, city, state, zip code, and email.
In the Responsibilities of Representative Organization section, select the options that authorize your representative to act on your behalf. Ensure both you and the organization sign this section.
If applicable, complete the Disclosure of Medical Information section by selecting options for sharing medical information with your representative.
Finally, sign and date the form in both the Signature of Representative Organization Employee and Signature of Applicant/Member sections. Make sure all required signatures are present before submission.

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