Forms

Forms

Frequently Used Forms


Below are frequently used forms. Please click to download.
Membership Application and Agreement
Complete this form to apply for membership to the Tennessee Farm Bureau. Membership is necessary to be eligible for coverage by Farm Bureau Health Plans.
Personal Representative Designation Form
Your completion of this form allows you to designate someone as your personal representative on your Farm Bureau Health Plans coverage.
Bank Draft Authorization Form
If you need to change your bank information for your monthly premium payment, complete this form, attach a voided check and mail both to Farm Bureau Health Plans.

ACA Bank Draft Authorization Form
If you have an ACA plan (FBHP: Gold, Bronze, Silver or Catastrophic) and need to change your bank information for your monthly premium payment, complete this form, attach a voided check and mail both to Farm Bureau Health Plans.

Other Insurance Form
You should always keep Farm Bureau Health Plans informed of other insurance that you and your dependents may have as Farm Bureau Health Plans coverage contains a coordination of benefits provision. Complete this form and mail it to Farm Bureau Health Plans when you obtain other insurance. 
Change Form
This form allows you to make changes to your current coverage.

FBHP ACA-Compliant Change Form
This form allows you to make changes to your current
ACA-Compliant coverage.

 

Forms Used With A New Application


Please select a form below to download with a new application.
Medical Request Form (age 0-2 months)
If applying for coverage, this medical request form contains the medical information required for children age 2 months and under.
Medical Request Form (age 2-25 months)
If applying for coverage, this medical request form
contains the medical information required for children
age 2 months to 25 months.
Medical Request Form (age 40 and older)
If applying for coverage, this medical request form contains the medical information required for individuals age 40 and older.
Patient Protection and Affordable Care Act 
Acknowledgment Form

This form is an acknowledgment that the 
Farm Bureau Health Plans coverage you are applying
for is not covered by the federal Patient Protection and
Affordable Care Act. This form may not be required for
the plan in which you are applying.
Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage (Medicare Replacement Form)
If you have a current Medicare Supplement or Medicare Advantage insurance and are replacing it with a Farm Bureau Health Plans Medicare Supplement, please complete this form.

Newborn Waiver Form
If you are applying for coverage and are currently
an expectant parent, completion of a Newborn Waiver
form will be required before the application can be processed.
The Newborn Waiver form establishes that the newborn child, 
upon delivery, will not have automatic coverage. A new 
application to add the newborn child will be required and the child will be underwritten. After the application process is complete, the newborn child will be added to the coverage on the next available effective date. 


Applications


Select the product below to download the application
Enhanced CHOICE FBHP Bronze B01CP
Direct CHOICE FBHP Bronze B01CPH (HSA-Qualified) 
Core CHOICE FBHP Silver S01CP
Major Medical FBHP Silver S01CPH (HSA-Qualified)
High Deductible Health Plan (HSA-Qualified)  FBHP Gold G01CP
Complete Care FBHP Catastrophic C01CP 
Value Care Dental Care
Premier Short Term Care
Child Coverage
 

Request for Reconsideration


Please select a form to download for reconsideration.
Request for Reconsideration of Benefit Exclusion Rider
This form is for you to complete when submitting a request for reconsideration of a benefit exclusion rider that has been placed on you or any dependents. Please use one form per rider being reviewed.
Request for Reconsideration of Declined Coverage
This form is for you to complete when submitting a request for reconsideration of declined coverage for you or any dependents.
Request for Reconsideration of Rate
This form is for you to complete when submitting a request for reconsideration of your rate for coverage.
Request for Reconsideration of Tobacco Rate
This form is for you to complete and submit if you (or anyone on your contract) have not used tobacco in over 24 months and would like to send a request to change to a non-tobacco rate.

 

Other Useful Forms


Please select a form below to download.
Under 65 Grandfathered Application
This application is for members that have Farm Bureau Health Plans Grandfathered coverage. Grandfathered coverage is that which went into effect before 03/23/2010.
Notice of Privacy Practices
This notice explains your rights to privacy and how Farm Bureau Health Plans may use your protected health care information.
Grievance Form
Use this form to submit a formal request for a review of an adverse benefit determination.
Prescription Drug Claim Form for Mail Order
This form is for you to complete for your mail order prescription.
Request For Medical Records
This is a blank request form for any type of medical records that needs to be requested.
 

 

Claim Forms


Before July 1, 2015 On or After July 1, 2015
Under 65 Health Coverage Claim Form 
Most providers will file health care claims for you. However, should you need to file a claim with a date of service before July 1, 2015, please complete this form.                  
Under 65 Health Coverage Claim Form
Most providers will file health care claims for you. However, should you need to file a claim with a date of service on or after July 1, 2015, please complete this form. 
Medicare Supplement Health
Coverage Claim Form 

Most providers will file health care claims for you. However, should you need to file a claim with a date of service before July 1, 2015, please complete this form.
Medicare Supplement Health
Coverage Claim Form

Most providers will file health care claims for you. However, should you need to file a claim, please complete this form.

 
Under 65 Prescription Drug Claim Form
To file prescription drug claims, complete this form and attach your prescription receipt or a print-out of your prescriptions signed by your pharmacist.
Under 65 Prescription Drug Claim Form
To file prescription drug claims for out of network pharmacies, complete this form and attach your prescription receipt or a print-out of your prescriptions signed by your pharmacist. All in-network claims will be filed electronically. 

 
Medicare Supplement Prescription
Drug Claim Form

To file prescription drug claims, complete this form and attach your prescription receipt or a print-out of your prescriptions signed by your pharmacist.
Medicare Supplement Prescription
Drug Claim Form

To file prescription drug claims, complete this form and attach your prescription receipt or a print-out of your prescriptions signed by your pharmacist.   

 

Ready to Apply Now?

Farm Bureau Health Plans is proud to offer quality coverage at an affordable cost. Get a rate quote and download an application to get started.

Medicare Supplements Insured by TRH Health Insurance Company, Columbia, TN.
TRHH-POST-POLA-FL14-174; TRHH-POST-POLB-FL14-175; TRHH-POST-POLC-FL14-176; TRHH-POST-POLD-FL14-177; 
TRHH-POST-POLF-FL14-178; TRHH-POST-POLG-FL14-179; TRHH-POST-POLM-FL14-180; TRHH-POST-POLAN-FL14-181
Not connected with or endorsed by the U.S. or state government. This is a solicitation of insurance. A representative of TRH Health Insurance Company may contact you. Benefits not provided for expenses incurred while coverage under the policy is not in force, expenses payable by Medicare, non- Medicare eligible expenses or any Medicare deductible or copayment/coinsurance or other expenses not covered under the policy.