Tenncare Long Term Services and Supports

TennCare Long Term Services and Supports

Request for NF (ICF) Admission

Member Information:

Applicant’s Name: Type Name. / SSN: Enter SSN here.
Age: Enter Age here. / Date of Birth: Enter DOB here.
Applicant Contact Phone #: Enter Phone # here. / Applicant Alternative Phone #: Enter Phone # here.
Designee/Conservator Name: Type Name. / Designee/Conservator Phone #: Enter Phone # here.
Requested Disenrollment Date: Enter a date. / Requested Disenrollment Type: Choose Dis-enrollment Type
Enrollment Prioritization Type: Choose PG OR RC. / Current enrollment Group: Choose an item.

Submitter:

Submitting agency: Choose Submitter. Contact Name: Type Name.
Contact Phone Number:
Type Phone #. / Contact Fax Number:
Type Fax #. / Contact Email Address:
Type Email.

Nursing Facility Short Term Stay:

Name of facility / Type Name of facility.
Date of admission (should be future date) / Click here to enter a date.
Anticipated length of stay / Type Anticipated length of stay.
Services offered/ tried in the community / Type Services offered/ tried in the community.

Nursing Facility Long Term (with Transition to CHOICES Group 1):

Name of facility / Type Name of facility.
Date of admission (should be future date) / Click here to enter the future date.
CHOICES PAE CN / Type PAE Control #.
Services offered/ tried in the community / Type Services offered/ tried in the community.

ICF/ IID:

Name of facility / Type Name of facility.
Date of admission (should be future date) / Click here to enter the future date.
Services offered/ tried in the community / Type Services offered/ tried in the community.
Signature of person completing this form / Title of person completing this form
Type Title Here. / Date
Click here to enter a date.

______

For TennCare use only:

☐Approved

☐ Deferred: Type the reason why the decision was deferred.

TC-1088 (Rev. 10-5-17) RDA 2046