Forms
- Enrollment Change Application – Active Members and COBRA (2025)
- TennCare Notice
- Corrections and Clarifications Form
- Administrative Error Form - Higher Education, Local Education & Local Government
- Fax Document Separator
- Agency ACH Form
- Individual Authorization Agreement for Preauthorized Payment (for Retirees and COBRA only)
- Certificate of Incapacitation for Dependent Child
- Request for Claims/Enrollment Data
- To request large claims data for premium bids, email benefits.privacy@tn.gov
- Insurance Cancel Request Application
- Dependent Verification Fax Transmittal Sheet
- Securian (Minnesota Life) Order Form
- Certification of Eligibility for Dependents by Valid Placement Order Form
- Certification of Eligibility for Dependents with Expired Placement Order Form
- Cigna DHMO Onsite Dentistry - Jet Dental
Security Authorization Form
- Edison Benefits User Security Authorization Form - State
- Instructions for Edison Benefits User Security Authorization Form – State
- VIDEO GUIDE: Edison Benefits User Security Authorization Form – State
- Edison Benefits User Security Authorization Form - Higher Education, Local Education & Local Government
- Instructions for Edison Benefits User Security Authorization Form – Higher Education, Local Education & Local Government
- VIDEO GUIDE: Edison Benefits User Security Authorization Form – Higher Education, Local Education & Local Government