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Insurance Complaint Form

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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

May

AMA at 175: Our national partner contributing to Nebraska Medical Association’s success

Feb

2022 NMA Legislative Breakfast

Sep

Nebraska Licensing and Certification Environment (Lance Project)

Aug

Introducing Lindsey Hanlon as the LifeBridge Nebraska Program Coordinator

View All Events

Aug

2022 Webinar Series - COPIC

News + Events

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