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Address Change

Billing Address

Update Requested By

Billing Address

Facility Name

If Facility based / Ancillary provider, please download the Nebraska Total Care Facility Application (PDF) and attach it in the upload field. The Nebraska Total Care Facility Application is applicable in circumstances where there is a Group NPI update and a service location update coinciding.

Practitioner Name

If multiple practitioners' provider updates are needed, please download the Nebraska Total Care Roster Template and attach it in the upload field. All roster fields are required.

Nebraska Total Care Roster Template (Excel)
(Roster template revised 12/21/2021)

Old Service Location Address

New Service Location Address

Office Hours

Update Requested By

Facility Name

If Facility based / Ancillary provider, please download the Nebraska Total Care Facility Application (PDF) and attach it in the upload field. The Nebraska Total Care Facility Application is applicable in circumstances where there is a Group NPI update and a service location update coinciding.

Practitioner Name

If multiple practitioners' provider updates are needed, please download the Nebraska Total Care Roster Template and attach it in the upload field. All roster fields are required.

Nebraska Total Care Roster Template (Excel)
(Roster template revised 12/21/2021)

Additional Location Address

Office Hours

Update Requested By

If multiple practitioners' provider updates are needed, please download the Nebraska Total Care Roster Template and attach it in the upload field. All roster fields are required.

Nebraska Total Care Roster Template (Excel)
(Roster template revised 12/21/2021)

Practitioner Name

Delete Location Address

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.