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Address Change

What would you like to do? Update a Billing Address Change a Service Location Add an Additional Service Location Remove a Location

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Group/Facility Name *

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Tax ID # *

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Group NPI # *

Error: This field is required.

Effective Date *

Error: This field is required.

Billing Address

Street Address *

Error: This field is required.

Address Line 2

City *

Error: This field is required.

State *

Error: This field is required.

Zip Code *

Error: This field is required.

Billing Address Phone Number *

Error: This field is required.

Please attach a completed IRS W-9 Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Comments

Update Requested By

First Name *

Error: This field is required.

Last Name *

Error: This field is required.

Contact Email *

Error: This field is required.

Contact Phone Number *

Error: This field is required.

Date Requested *

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Error: Please add a Captcha.

Billing Address

Group/Facility Name *

Error: This field is required.

Group NPI # *

Error: This field is required.

Tax ID # *

Error: This field is required.

Effective Date *

Error: This field is required.

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.

Facility Application

Items in the trash will be permanently removed after 30 days.

Practitioner Name

First Name

Last Name

Practitioner NPI #

Multiple Practioners

Items in the trash will be permanently removed after 30 days.

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 03/02/2023)

Old Service Location Address

Street Address *

Error: This field is required.

Address Line 2

City *

Error: This field is required.

State *

Error: This field is required.

Zip Code *

Error: This field is required.

New Service Location Address

Is the address change for a primary location? * Yes No

Error: This field is required.

Street Address *

Error: This field is required.

Address Line 2

City *

Error: This field is required.

State *

Error: This field is required.

Zip Code *

Error: This field is required.

Primary Phone *

Error: This field is required.

Is your billing address also changing? * Yes No

Error: This field is required.

Street Address *

Error: This field is required.

Address Line 2

City *

Error: This field is required.

State *

Error: This field is required.

Zip Code *

Error: This field is required.

Billing Address Phone Number *

Error: This field is required.

Please attach a completed IRS W-9 Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Office Hours

Sunday *

Error: This field is required.

Monday *

Error: This field is required.

Tuesday *

Error: This field is required.

Wednesday *

Error: This field is required.

Thursday *

Error: This field is required.

Friday *

Error: This field is required.

Saturday *

Error: This field is required.

Comments

Update Requested By

First Name *

Error: This field is required.

Last Name *

Error: This field is required.

Contact Email *

Error: This field is required.

Contact Phone Number *

Error: This field is required.

Date Requested *

Error: This field is required.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

Group/Facility Name *

Error: This field is required.

Group NPI # *

Error: This field is required.

Tax ID # *

Error: This field is required.

Effective Date *

Error: This field is required.

Facility Name

Facility Application

Items in the trash will be permanently removed after 30 days.

Practitioner Name

First Name

Last Name

Practitioner NPI #

Multiple Practioners

Items in the trash will be permanently removed after 30 days.

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 03/02/2023)

Additional Location Address

Street Address *

Error: This field is required.

Address Line 2

City *

Error: This field is required.

State *

Error: This field is required.

Zip Code *

Error: This field is required.

Location Phone Number *

Error: This field is required.

Is your billing address also changing? * Yes No

Error: This field is required.

Street Address *

Error: This field is required.

Address Line 2

City *

Error: This field is required.

State *

Error: This field is required.

Zip Code *

Error: This field is required.

Billing Address Phone Number *

Error: This field is required.

Please attach a completed IRS W-9 Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Comments

Office Hours

Sunday *

Error: This field is required.

Monday *

Error: This field is required.

Tuesday *

Error: This field is required.

Wednesday *

Error: This field is required.

Thursday *

Error: This field is required.

Friday *

Error: This field is required.

Saturday *

Error: This field is required.

Comments

Update Requested By

First Name *

Error: This field is required.

Last Name *

Error: This field is required.

Contact Email *

Error: This field is required.

Contact Phone Number *

Error: This field is required.

Date Requested *

Error: This field is required.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

Group/Facility Name *

Error: This field is required.

Group NPI # *

Error: This field is required.

Tax ID # *

Error: This field is required.

Effective Date *

Error: This field is required.

Multiple Practioners

Items in the trash will be permanently removed after 30 days.

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 03/02/2023)

Practitioner Name

First Name

Last Name

Practitioner NPI #

Delete Location Address

Street Address *

Error: This field is required.

Address Line 2

City *

Error: This field is required.

State *

Error: This field is required.

Zip Code *

Error: This field is required.

Location Phone Number *

Error: This field is required.

Comments

Update Requested By

First Name *

Error: This field is required.

Last Name *

Error: This field is required.

Contact Email *

Error: This field is required.

Contact Phone Number *

Error: This field is required.

Date Requested *

Error: This field is required.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

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.

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