Security Officer
Resume:
TN***B
Your TennCare Application Summary
Here is a summary of what you told us using the TennCare Connect on 06/21/2022.
*** Keep in mind that you do not need to mail this to us. It is only for your reference. *** Thank you for using TennCare Connect to apply for benefits on 06/21/2022. Your application tracking number is T52458485. You will need this number if you want information about the status of your application.
TennCare Application Summary
Division of TennCare
2
Head of Household
Audra Wright Age: 55
What language do you
speak most often?
Other Language Preferred language for
letters
English N/A English
Where You Live Mailing Address
909 North Highland Ave Apt B
Jackson, TN 38301
Madison County
909 North Highland Ave Apt B
Jackson, TN 38301
Madison County
Home Phone Cell Phone Work Phone Best time to call you
731-***-**** 731-***-**** Not Answered Anytime Written language Spoken language
English English
Who is completing this application? Would you like to add an Assisting Person to your application?
Self No
People In Your Home
Audra Wright Age: 55
Applying for coverage? Known by another name? If yes, name? Yes No N/A
Gender Date of birth Social Security
Number
Date applied for an
SSN
Female 10/25/1966 ***-**-**** N/A
US Citizen or
national?
Naturalized or
derived US
citizen?
Alien Number Naturalization
Certificate Number
Yes No N/A N/A
Living arrangement Tennessee Resident? Living out-of-state? At Home Yes No
If yes, plan to return? Date planned to return
N/A N/A
TennCare Application Summary
Division of TennCare
3
Race Ethnicity Member of a
federally
recognized tribe?
Name of the tribe
Black / African
American
Other No N/A
Received service from Indian Health
Service through a referral?
Eligible to get services from Indian Health
Services?
N/A N/A
School enrollment status Working full time?
N/A N/A
Pregnant?
No
Any other past pregnancies to report?
No
Former foster care? Has anyone experienced an emergency health problem and needs help paying
for those emergency services?
N/A N/A
Self Employment
Audra Wright Age: 55
Business Name Type of self-employment Business Description Creative Spirits A F Other creating art
Net income this month? Does anyone co-own this
Self-Employment with you?
If yes, who?
$0.00 No N/A
TennCare Application Summary
Division of TennCare
4
Additional Questions
Does anyone have Medicare and want to get or keep help paying their Medicare costs (like premiums and copays)? You might know this kind of help as QMB or SLMB.
No
Did anyone in the household go to the health department for temporary coverage so they could get treatment for breast or cervical cancer? No
Is anyone in the household under the age of 18 applying for the Katie Beckett program?
Not Answered
Does anyone in the household have bills (paid or unpaid) for medical care, dental care, or medicine received in the last 3 months? Or have you paid for these kinds of care out of pocket or paid on any of those bills for this month? N/A
Is anyone living in a nursing home now or needs this kind of care but does not live in a nursing home?
No
Is anyone in your household in a medical facility like a hospital now and will be there for at least 30 days?
No
Does anyone in your household need hospice care?
No
Does anyone in your household want to receive Home and Community Based Services (HCBS) but does not currently receive them? No
Does anyone in your household have intellectual and/or other developmental disabilities and want to receive Home and Community Based Services (HCBS) and participate in Employment and Community First CHOICES? No
TennCare Application Summary
Division of TennCare
5
Additional Questions
Does anyone in your household have intellectual or development disabilities and want care at home or at an intermediate care facility. No
Does anyone in your household have shelter or utility expenses, dependent care expenses, or child support expenses?
Not Answered
Does anyone in your household have resources like financial accounts, vehicles, property, burial resources, or life insurance?
Not Answered
Review Your Comments
Audra Wright Age: 55
Summary of Comments
Comment added through members TennCare Connect Account: I have a license but I have not started producing or selling yet still in the process of preparing to open. TennCare Application Summary
Division of TennCare
6
Voter Registration
Audra L Wright 55
Are you registered to vote where you live now?
Yes
Would you like us to mail you a voter registration application? No
Note :
You do not have to be registered to vote to be enrolled in our program. And, if you decide not to register, that will not change our decision on your application. If you want help registering to vote, we'll help you. Call us at 855-***-**** and tell us you want help.
If you think someone has interfered with your right to vote, you can file a complaint. Mail your complaint to: Division of Elections
312 Rosa L. Parks Avenue
7th Floor, Snodgrass Tower
Nashville, TN 37243-1102
Or call: 877-***-****
Individuals with hearing or speech impairments can use Tennessee Relay Center: 800-***-****
TennCare Application Summary
Division of TennCare
7
Renewal of Coverage in Future Years
Permission to try to renew my eligibility automatically? Yes, for the next 5 Years (the maximum number of years allowed). Note:
We must renew your eligibility every year to see if you still qualify. We can try to renew your eligibility automatically (for up to 5 years) using federal information sources like information from your tax returns and employment. But we need your permission to check this information. If you don't give us permission, that's ok. Would you like us to try to renew your eligibility automatically?
TennCare Application Summary
Division of TennCare
8
Managed Care Organizations
Preferred health plan
Not Answered
Note:
The health plans for TennCare Medicaid are: AMERIGROUP, BlueCare, and United Healthcare Community Plan.
TennCare Medicaid and CoverKids
If you are approved for TennCare Medicaid or CoverKids, there are three health plans to choose from. We'll try to enroll you in the health plan you choose. In most cases, everyone in your home who is approved for TennCare Medicaid will be enrolled in the same health plan. If you don’t pick one now, we can pick one for you. The health plans for TennCare Medicaid or CoverKids are: AMERIGROUP, BlueCare, and UnitedHealthcare Community Plan.
If you are approved for TennCare Medicaid or CoverKids, your approval letter will tell you who your plan is and explain how to change your health plan. For more information about the health plans in your area, visit the <TennCare website>. Medicare Savings Programs (MSPs)
Do you have Medicare? If so and if you only qualify to get TennCare's help paying for your Medicare costs through a program like QMB (Qualified Medicare Beneficiary) or SLMB
(Specified Low-income Medicare Beneficiary), you won't have a TennCare health plan. Electronic Signature
Applicant signature
Audra L Wright
Details
TennCare Application Summary
Division of TennCare
9
I'm signing this page under penalty of perjury which means I've provided true answers to all the questions to apply for or renew health coverage or report changes for the persons named in this application and its supplements to the best of my knowledge. I also certify that:
I agree to submit this application by electronic means. By signing this application electronically, I understand that an electronic signature has the same legal effect and can be enforced in the same ways as a written signature. I understand the questions and statements on this application. I have read and understand my Rights & Responsibilities. I know that I may be subject to penalties under state and federal law if I provide false and or untrue information.
TennCare Application Summary
Division of TennCare
10
Rights and Responsibilities
· I know that I must tell TennCare if anything changes (and is different than) what I answered on the application or Renewal Packet within 10 days of that change. I can call 855-***-**** to report any changes. I understand that a change in my information could affect the eligibility for member(s) of my household.
· I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. If you think you have been treated unfairly, call 855-***-**** to report it. It’s a free call.
· I know that if I am approved, I can’t keep any health insurance or medical payments I get from insurance or other companies. Those payments belong to the State. I understand I must sign them over to the State.
· I know that if the Tennessee Bureau of Investigation, TennCare, Office of Inspector General, or another agency asks for my help catching health care fraud and abuse, I must help.
· I know if the state pays for medical bills or for nursing home care for me, the state may get that money back. I know that after my death, the State may be paid back with money from my estate.
· I know no one else can use my health care card. I know if I let someone else use my card I may have to pay the State back for that other person’s medical bills. And I could go to jail.
· If I have a Social Security Number (SSN) and I’m applying for coverage, I know I am required to provide a valid SSN. Federal and State law lets us ask for an SSN. [42 CFR 435.910; Tenn. Code Ann § 71-5-106]
· If anyone on the application or Renewal Packet is eligible for health care coverage with TennCare, I am giving to TennCare rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I am also giving to TennCare rights to pursue and get medical support from a spouse or parent.
TennCare Application Summary
Division of TennCare
11
Rights and Responsibilities
· Does any child on this application or Renewal Packet have a parent living outside of the home? If yes, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell TennCare and I may not have to cooperate.
· If I think TennCare or CoverKids (CHIP) has made a mistake, I can appeal its decision. To appeal means to tell someone that I think the action is wrong, and ask for a fair review of the action. I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me. I know that I can find out how to appeal by contacting the Tennessee Health Connection at 855-***-****.
Your Right to Privacy
We know you value the privacy of your personal information. Federal law says we must follow privacy rules to keep your facts private. You can read about the rules on our website. For more information about our privacy rules, go to https://tn.gov/tenncare and choose Policy and Guidelines. If you want us to mail you a copy, call the Tennessee Health Connection for free at 855-***-****.
Non-Discrimination
We do not allow unfair treatment in our program.
No one is treated in a different way because of race, color, birthplace, religion, language, sex, age, or disability. Do you think you’ve been treated unfairly? Do you have more questions? Do you need more help? You can make a free call to the Tennessee Health Connection at 855-***-****. Or go to
http://www.tn.gov/tenncare/topic/non-discrimination-compliance to learn more.
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