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Demographic Change

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Service Location Address

Update Requested By

Practitioner Current Name

Practitioner New Name

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Practitioner Name

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Practitioner Name

Service Location Address

New Provider Office Hours

Update Requested By

Service Location Address

Service Location Office Hours

Update Requested By

 

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.