Demographic Change

What do you want to do? * Change Phone Number Change Practitioner Name Add/Remove a Language Spoken Update Practitioner Office Hours Update Service Location Office Hours

Group/Facility Name *

Tax ID # *

Group NPI # *

Service Location Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Old Phone Number *

New Phone Number *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

Practitioner NPI # *

Practitioner Current Name

First Name *

Last Name *

Suffix

Practitioner New Name

First Name *

Last Name *

Suffix

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

Practitioner NPI # *

Practitioner Name

First Name *

Last Name *

Additional Language(s) Spoken *

Language(s) No Longer Spoken *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

Practitioner NPI # *

Practitioner Name

First Name *

Last Name *

Group Name *

Service Location Address

Street Address *

Address Line 2

City *

State *

Zip Code *

New Provider Office Hours

Sunday *

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Saturday *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

Group/Facility Name *

Group NPI # *

Service Location Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Service Location Office Hours

Sunday *

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Saturday *

Comments

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested *

This form will send your message to Nebraska Total Care as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Nebraska Total Care through email, you accept associated risks. Nebraska Total Care does not accept responsibility or liability for any loss or damage arising from the use of email.

To ensure the safety of your protected health information (PHI), please send a secure email message directly to our Contract Coordinators at NetworkManagement@NebraskaTotalCare.com while providing the Group NPI in reference.

Additionally, status updates are achieved with a direct email to our Contract Coordinators at NetworkManagement@NebraskaTotalCare.com, including the Group NPI and practitioner’s NPI(s) as applicable.