Member Handbooks and Forms
Nebraska Total Care provides members with our member handbook and a variety of other forms. Our member handbook provides details about Nebraska Total Care and Heritage Health services offerings. The Nebraska Total Care Member Handbook includes:
- Information about your benefits
- Your rights and responsibilities
- Member satisfaction
- How to choose your Primary Care Provider (PCP)
- When to use urgent care instead of the emergency room
Please take time to look over your handbook. Keep it handy in case you need it. You have the option to receive this handbook at least once a year. You can get it in either an electronic or a paper format. You can always see it here on our website.
Nebraska Total Care Member Handbook 2024 (PDF) (effective January 1, 2024)
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.
- Notice of Pregnancy NOP (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 117th Ave, Suite 100
Omaha, NE 68164
Nebraska Total Care can help
If you need help understanding your Member Handbook or completing these forms, please call Member Services. The phone number is 1-844-385-2192 (TTY 711). If you need our written materials translated into a language other than English, please call Member Services. We can also provide some things in other formats such as Braille, CD or large print.
A screen reader may be used to translate visual information verbally. NVDA is a free, open source, globally accessible screen reader for the blind and vision impaired. The NVDA screen reader can be downloaded free of charge by anyone. Get the NVDA User Guide.