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Add a New Provider or Term an Existing Provider

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

Primary Care Provider (PCP) Name

Practitioner will be termed from all locations associated with this TIN.

Update Requested By

Specialist Name

Practitioner will be termed from all locations associated with this TIN.

Update Requested By