Join Our Network

Thank you for your interest in participating in the Ambetter from Nebraska Total Care network! If you would like to receive more information on becoming a provider within our network, please complete the form below.

Required fields are marked with an asterisk (*)

Enter Provider Name *

Specialty *

Sub-Specialty

Enter Provider NPI Number *

Enter Provider Tax ID Number *

Mailing Address Line 1 *

Mailing Address Line 2

City *

State *

Zip Code *

County *

Primary Hospital Affiliation *

Hospital Affiliation 2 (optional)

Hospital Affiliation 3 (optional)

Do You Have Additional Hospital Affiliations?

Yes No

Contact Name *

Phone Number *

Contact Email *

Practice Location Zip Code 1 *

Practice Location Zip Code 2

Practice Location Zip Code 3

Please download and fill out the IRS W-9 Form.

Please upload IRS W-9 Form

Disclaimer: This form will send your message to Ambetter from Nebraska Total Care as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Ambetter from Nebraska Total Care through email, you accept associated risks. Ambetter from Nebraska Total Care does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your PHI, please send us a message through the Secure Member or Provider portal.

Agreement*

I understand that this inquiry does not guarantee my participation in the Ambetter network.

Agreement*

I understand that failure to complete this inquiry accurately and completely will result in the delay of evaluating my request.

Become An Ambetter Provider in Nebraska | Ambetter from Nebraska Total Care

Join Our Network