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Add a New Provider or Term an Existing Provider

Product Type*
Choose all products that apply.

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)

Primary Care Provider (PCP) Name

Practitioner will be termed from all locations associated with this TIN.
Use date format MM/DD/YYYY

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 1/13/2022)

Update Requested By

Use date format MM/DD/YYYY

Specialist Name

Practitioner will be termed from all locations associated with this TIN.
Use date format MM/DD/YYYY

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 1/13/2022)

Update Requested By

Use date format MM/DD/YYYY

 

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.