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Insurance Complaint Form

Carrier Information

Name of Carrier

Address

City

State

Zip Code

Carrier Phone #

Is the plan self-funded or self-insured?

Is the claim under a network provider?

Name of Network

Claim Information

Type of Problem

Without disclosing Protected Health Information (PHI), please describe briefly the nature of the claim issue

Do you have documentation of the problem you described above?

Claim No.

Describe the type of documentation you have

Physician Information

Physician Name

Address

City

State

Zip Code

Specialty

Phone

Fax

Email Address

Date

Month

Day

Year

Contact Person

Members Page

News
Events

View All News

Jul

Registration now open for 2019 Annual Membership Meeting

Jun

DHHS Abuse and Neglect Hotline Now Accepting Calls from Medical Professionals for Children Age Five and Under

Jun

Governor Ricketts Proclaims June Men's Health Month

May

2019-20 NMA Physician's Leadership Academy Now Accepting Applications

View All Events

Sep

2019 Nebraska Medical Association Annual Membership Meeting

Jan

NMA Annual Advocacy Breakfast

News + Events

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