Tennessee Eligibility/Termination Notification
Provider
*
Amerigroup
Bluecare
United Health
Date of Form Submission
*
-
Month
-
Day
Year
Date
Member Name
*
First Name
Last Name
Members Subscriber ID Number
*
Start Date of Eligibility Issue or Termination
*
/
Month
/
Day
Year
Date
End Date of Eligibility Issue
/
Month
/
Day
Year
If Applicable
Service or Services Being Provided
*
Community Integration Support Services
Decision Making Supports
Family Caregiver Education and Training
Family Caregiver Stipend
Individual Education and Training
Assistive Technology
Transition Allowance
Notes/Additional Information
Support Coordinator/Provider Representative's Contact Info
Support Coordinator or Representative Completing Form
*
First Name
Last Name
Email
*
Confirmation Email
example@example.com
Phone Number
*
-
Area Code
Phone Number
Signature
Submit
Should be Empty: