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1919 Aksarben Drive Omaha Nebraska 68180-0001 www. nebraskablue. com Omaha Fax 402-548-4685 Grand Island Fax 308-381-6134 Lincoln Fax 402-477-2952 Customer Service Omaha 402-390-1820 Toll Free 888-592-8961 Hearing Impaired 402-390-1888 TTY/TDD Extension of Coverage Request For a mentally or physically handicapped Dependent. Full and correct completion of this form will assist Blue Cross and Blue Shield of Nebraska in determining whether or not a child is so entitled. Section I To be completed...
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