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Murfreesboro Tennessee Form 1310: What You Should Know

Please be sure to include your name and address, as well as the type of medical records you would like to receive. AVAILABLE: 11:00 AM — 4:00 PM Mon-Thurs; 9:00 AM — 4:00 PM Fri & Sat Medical Records Release Officer: Ms. Mavis Brown Records Release Office 4100 N. Central Dr Suite 110 Nashville, Tenn, 37 8 Aug 2023 — In the event of an increase or decrease in your claim for payment, submit an e-mail stating: “I have a change in my claim for payments.” We will then send you a new Form 1310(I) which will reflect your changes. Form 1310 PDF, 26 Aug 2023 (Rev. December 2021) You can fill out and file the form online or with a paper form or by mail. To complete the online portion, you will need to have the following information: Please be sure to include the following information in the mail or fax, including copies of your deceased spouse's Social Security Card, death certificate, and/or other proof of death. 1. Name of decedent. 2. If the deceased spouse received a medical certification, death certificate or other proof of death on or after January 1, 1989, you must identify the name, address and Social Security number of the certifying physician. In the event that you did not receive an original certification or other proof of death from a certifying physician, you should identify the name, address and Social Security number of the certifying physician. 3. You will also need to provide the deceased's date of birth or name of a person with whom the decedent had lived while resident in the United States from December 31, 1955, to December 31, 1988. If the decedent did not have a Social Security number while he or she was resident in the United States during the period covered, the Social Security number you provide must be the Social Security number issued to the decedent on December 31, 1955. To determine whether you have received medical certification or other proof of death, follow the instructions for Medical Records Release Officer in Section 4B of Section 3. A completed copy of the Federal Form 5498 or 5498-EZ must be included. If the deceased was receiving care in a hospital, hospital bills are included. If any of the required information is not on file with the medical facility (e.g.

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