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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

May

19

How one Nebraska addiction psychiatrist tirelessly advocates for her patients

May

04

NMA Teams Up with Lincoln Saltdogs for #ThankYouTuesday

Mar

30

Nebraska Governor Proclaims March 30, 2021, as Doctors Day

Mar

24

Recognizing and Treating Opioid Use Disorder

View All Events

Sep

17

2021 Annual Membership Meeting

News + Events

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