The following form is utilized by TennCare for processing a public records request. A requestor may use a copy of the form produced below or the electronic version of the form available on the TennCare website at https://www.tn.gov/tenncare/ (This space intentionally left blank) TENNCARE PUBLIC RECORDS REQUEST FORM The Tennessee Public Records Act (TPRA) grants Tennessee citizens the right to access open public records that exist at the time of the request. The TPRA does not require records custodians to compile information or create or recreate records that do not exist. To: TennCare Public Records Request Coordinator Department of Finance and Administration, Division of TennCare 310 Great Circle Road Nashville, TN 37243 1-866-797-9469, fax (615) 734-5289 email the completed form to Privacy.Records.TennCare@tn.gov From: Requestor Name:____________________________________________________________ Residence address:__________________________________________________________ Mailing or delivery information:__________________________________________________ __________________________________________________________________________ Phone:_______________________ Email:_______________________________________ Is the requestor a Tennessee citizen?_____Yes_____No (A copy of a valid driver’s license or other evidence showing requestor’s address is required prior to access to public records.) Request: _____Inspection (The TPRA does not permit copying fees or require a written request for inspection only. Fees may be assessed for redaction as appropriate.) _____Copies/Duplicates (There is no fee for requests for records of less than 10 pages and labor charges of one hour or less. If fees are to be assessed, the requestor has a right to receive a good faith estimate prior to receiving the documents requested. More details as to fees and charges may be found in the TennCare Public Records Policy.) Do you wish to waive your right to an estimate and agree to pay copying and duplication costs in an amount not to exceed $____________________? If so, initial here:_____________. Delivery preference: _____On-Site Pick-Up _____USPS First-Class Mail _____Electronic _____Other:_____________________________ Records Requested: Provide a detailed description of the records requested, including:

1. (1) type of records;
2. (2) timeframe or dates for the records sought; and
3. (3) subject matter or key words related to the records. Under the TPRA, records requests must be sufficiently detailed to enable a governmental entity to identify the specific records sought. As such, your records request must provide enough detail to enable the records custodian responding to the request to identify the specific records requested. Description:______________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________ Signature of Requestor and Date Submitted TENNCARE OFFICE USE ONLY Received by:_______________________________ Date and time received:______________________ Notes: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Authority: T.C.A. §§ 4-5-202, 10-7-503, and 71-5-105. Administrative History: Original rules filed January 3, 2019; effective April 3, 2019.