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Member Handbooks and Forms

This handbook tells you how Nebraska Total Care works and the services we offer. Your 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 (PDF)

Grievance or Appeal Form (PDF)
This form 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.

Health Information Form (PDF)
This form will help us find out if there are any extra information or services you need. 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

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. 

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

Notice of Pregnancy (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

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.

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 Avenue
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: 1-844-307-0342 or Relay 711)