Mandatory Report of Insurers Reporting Licensed Health Professionals

Insurers reporting Licensed Health Professionals for adverse judgment or settlement as a result of a suit, claim, or violation of insurance coverage, to the Division of Public Health - Investigations Unit.

State of Nebraska
Department of Health and Human Services, Division of Public Health
Office of Professional & Occupational Investigations
P.O. Box 94722, Lincoln, Nebraska 68509
PHONE: 402-471-0175
FAX: 402-742-8335
EMAIL: DHHS.InvestigationsPOL@nebraska.gov

Identifying Information For the Professional I am Reporting

Physical Address

Mailing Address

List the profession and license number for each Nebraska license, certificate, or registration held.

Profession
License Number

Reporting Party Information

Physical Address

Mailing Address




Patient or Client


Location of act, omission, or conduct being reported


Malpractice payment

Name of patient or client:
Address:
Name of court:
Address:

Name:
Title:
Address:
Phone:
Name:
Title:
Address:
Phone:
Name:
Title:
Address:
Phone:

Reason for Complaint

Please describe the complaint and include as much detail as possible.
Allowed file extensions: .tiff, .tif, .pdf, .doc, .docx, .jpg, .jpeg, .png and .gif
Max file size allowed: 20 MB.

The statements I have made are true and correct to the best of my knowledge. By signing this form, I am agreeing to the submission of this complaint by electronic means. I understand that an electronic signature has the same legal effect and enforceability as a written signature on a complaint.

3/28/2024