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

Prefix

First Name

Last Name

Middle Initial

Suffix

Primary Phone

Alt Phone

Fax

Contact Email

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Is Mailing Address the same as Physical Address?

Yes

Mailing Address

Address Line 1

Address Line 2

PO Box

City

State

Zip Code

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

Profession

License Number

Reporting Party Information

Business Name

Contact/Owner Prefix

Contact/Owner First Name

Contact/Owner Last Name

Contact/Owner Middle Initial

Contact/Owner Suffix

Primary Phone

Alt Phone

Fax

Email Address

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Is Mailing Address the same as Physical Address?

Yes

Mailing Address

Address Line 1

Address Line 2

PO Box

City

State

Zip Code

Relationship to Health Care Professional

Preferred method of contact:

Do you wish to remain anonymous?

Yes

1. We have made a payment resulting from a professional liability claim.

2. We have taken an adverse action that affects the coverage provided by the insurer due to alleged:

3. The insurer has reasonable grounds to believe that the practitioner has committed a violation of the regulatory provisions governing the profession or practitioner.

4. The Department has requested the insurer to provide information.

Patient or Client

Name

Date of Birth

Address

Location of act, omission, or conduct being reported

Location Name

Address

Date of occurance:

Malpractice payment

Name of patient or client:

Address:

Name of court:

Address:

Date of judgment, settlement, or award:

Date of payment:

Amount of payment:

List all persons present at time of incident that would have first-hand knowledge of the incident.

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.

Attach any additional documentation.

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.

Please sign by typing your name below.

Date

11/21/2024

Public Health Investigations

Department of Health and Human Services

Division of Public Health
Investigations - Healthcare Professionals and Occupations

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.

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.

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