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Contract Request Form

Required fields are marked with an asterisk (*)

Contract Type *
Contract products currently effective: required *
Choose all products that apply.
Contract products you are requesting to add: required *
Choose all products that apply.

Provider Information

Provider Identification Numbers

Provider Type required *

IRS W-9 Form (PDF) (opens in new window)

Please download and fill out the IRS W-9 Form linked above, then attach it to the form.

 

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 us a message through the Secure Member or Provider portal.