Liberty Nebraska Feedback

Please feel free to enter any feedback into this form. A manager or director will contact you within 2 business days for time-sensitive feedback and 5 business days for all others. Reach out to Nebraska.Quality.Help@libertyhealth.com for help with this process.

Question Title

* 1. Date

Date / Time

Date

Time

AM/PM

Question Title

* 2. Is this time-sensitive?

Yes

Question Title

* 3. Department feedback is relation to

Mortality Review

Incident Management

Human and Legal Rights

Provider On-site Review

General Feedback

Other (please specify)

None of the above

Question Title

* 4. Name of Reporter

Question Title

* 5. Contact information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 6. Type of Reporter

DHHS-DDD Employee

Waiver Participant

Family or Guardian of Waiver Participant

Waiver Provider

Advocate other than family/guardian

Other (please specify)

Liberty Nebraska Feedback

Question Title

* 1. Date

Question Title

* 2. Is this time-sensitive?

Question Title

* 3. Department feedback is relation to

Question Title

* 4. Name of Reporter

Question Title

* 5. Contact information

Question Title

* 6. Type of Reporter

Question Title

* 7. Description of the feedback