•	Application for Enrollment
•	Application for Premium Assistance
•	Attending Physicians Statement if you need to demonstrate uninsurability
•	Information Packet
•	Checklist
•	Application and Language Assistance Information

A Spanish language version is available for the AccessTN application and the Premium Assistance application. Language Assistance is available in these languages:

Spanish/ Español 1-866-626-3409 o al (615) 214-4944 en Nashville
Bosnian/Croatian/Serbian Bosanski (615) 313-9382 ili 1-877-652-3069 izvan Nashville
Somali Soomaali (615) 313-9894 Nashville gudaheeda, dibadeedana 1-877-652-3054
Vietnamese Tiêng Viet Xin g_i so (615) 313-9899 hoac so mien phi 1-800-269-4901
Kurdish-Badinani 1-866-626-3411
Kurdish-Sorani 1-866-626-3411
Arabic العربية 1-866-626-3411 من خارج ناشفل

If you have questions or need help with the application, call toll-free 1.866.636.0080.

When you have completed the application, sign and mail it to:
AccessTN
c/o BlueCross BlueShield of Tennessee, Inc.
801 Pine Street
Chattanooga, TN 37402

Please make a copy of your completed application for your files.