Forms, Policies, and Formulaires

Part A/MAI Forms
Letter of Medical Necessity, Updated July 2015
Request for Additional Funding Form, Updated May 2015
Comprehensive Monitoring Tool, Updated December 2015

Part A/MAI Policies
Grievance Policy and Reporting Form
Memphis TGA Eligibility Policy, Updated April 2015
Memphis TGA Transportation Policy, Updated March 2016
Memphis TGA Food Vouchers Policy, Updated March 2016
Memphis TGA Imposition & Assessment of Client Charges,  Updated September 2017
Memphis TGA Time and Effort Reporting, Updated September 2017
Memphis TGA Program Income, Updated September 2017

Part A/MAI Formularies
Local Pharmaceutical Assistance, Update March 2016
Laboratory Procedures, Updated March 2014
Oral Health Care – Beginning June 1, 2017, Part A will use the TN Part B formulary for oral health services. See below. If you have any questions, please contact your fiscal specialist

Tennessee Part B Forms
2017 Poverty Guidelines, Updated February 2017
Modified Adjusted Gross Income (MAGI) Worksheet, Updated February 2017

Tennessee Part B Policies
Medical Case Management Manual, Updated September 2017
Services Eligibility Policy
Housing Referral Services and Short Term Emergency Housing Needs Policy, Updated September 2017

Tennessee Part B Formularies
AIDS Drug Assistance Program (ADAP), Updated July 2016
Medical Services Fee Schedule, including Oral Health, Updated May 2018

Other Resources
Ryan White Part A-MAI Fiscal Update & Review, September 2017