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Affidavit of Notice to TennCare

A duly appointed affiant who acts as the personal representative of an intestate estate must execute this affidavit. In this form, affiant declares that the decedent was able to provide the TennCare Eligibility Verification (or Request for Release of Estate Recovery Cost Claim) to the Bureau of TennCare as said decedent was at least 55 years old at the time of her/his death.

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