Member Handbooks and Forms

Grievance and Appeals Forms

These forms can be used to file a grievance or appeal. Information about where to send it is on the form. More information about these processes can be found on our Complaints and Appeals page.

• Grievance Form (PDF)
• Appeal Form (PDF)
  
• Nebraska DHHS Appeal Form (PDF) (State Fair Hearing request) - This form is used if you have used your appeal rights and want an additional review by the state. More information about this process can be found on our Filing an Appeal page. 
• Member Authorized Representative Designation Form (PDF) - This form gives your permission for someone else to act on your behalf in an appeal or grievance. More information about these processes can be found on our Complaints and Appeals page.

HIPAA Forms

• HIPAA Authorization to Disclose Health Information Form (PDF) - Completing this form will allow Nebraska Total Care to share your health information with the person or group that you identify.
• HIPAA Revocation of Authorization to Disclose Health Information Form (PDF) - Use this form to cancel your Authorization to Disclose Health Information. 

Other Forms

• Health Risk Screening (in portal). Help Nebraska Total Care provide you additional services and assistance you may need. If you are in the HHA Demonstration Program, you must complete the HRS to qualify for Prime benefits. You must answer every question. You can complete the form in the Member Portal. Would it be easier to do your Health Risk Screening over the phone? Call Member Services. Or return the completed form to:

Medical Management Notifications
PO Box 2010
Farmington MO 63640- 9706

• Homelessness Identification Form (PDF) - If you are homeless or at risk of becoming homeless, you may submit this form for assistance and your Heritage Health plan will contact you. Assistance could include connecting you with housing, food, transportation and other services available to you.

• Medically Complex Self-Identification Form (PDF) - If you have one or more medical problems that negatively affect your health, you may submit this form for assistance. Your Heritage Health plan will contact you to provide extra help for your health conditions and other needs.

• Notification of Pregnancy NOP Form (PDF) - This form will help us give you extra information and support you need during and after pregnancy. You can complete the form in the Member Portal or it can be mailed to:
  
  Medical Management Notifications
  PO Box 2010
  Farmington, MO  63640-9706
  
  
• Primary Care Provider Change Form (PDF) - This form tells us that you want to change your Primary Care Provider. You can change your Primary Care Provider in the Member Portal or mail this form to:
  
  Nebraska Total Care
  2525 N 117^th Ave, Suite 100
  Omaha, NE 68164