Your shopping cart is empty.

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

10

Nebraska Licensing and Certification Environment (Lance Project)

Aug

27

Introducing Lindsey Hanlon as the LifeBridge Nebraska Program Coordinator

Aug

06

Licensure Renewal 8/6/21

Aug

04

Delta-8 THC Latest Hemp Derivative Spurring Growing Market

View All Events

Feb

01

NMA Annual Advocacy Breakfast

News + Events

hardcoded background image