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Insurance Complaint Form

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

Sep

11

Rob Rhodes, MD, installed as president of the Nebraska Medical Association

Sep

07

Nebraska joins 37 other states with passage of Good Samaritan drug overdose immunity law

Aug

25

DHHS requires Corrective Action Plan for WellCare

Aug

22

Hospices grapple with stolen meds

View All Events

Jan

23

2018 Advocacy Breakfast

News + Events

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