Forms, Policies, and Formulaires

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

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

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

Tennessee Part B Policies
Services Eligibility Policy
Housing Referral Services and Short Term Emergency Housing Needs Policy, Updated April 2017

Tennessee Part B Formularies
AIDS Drug Assistance Program (ADAP), Updated July 2016
Oral Health, Updated April 2017