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Provider / Become a Network Provider / Facility/Ancillary App

Facility/Ancillary Application

  • Please complete one form per practice. 
  • You may choose to submit this application electronically by entering the information below, or to fax or mail a printed version of this application. 
  • Submitting this application request form does not constitute in-network status with the SummaCare network.
  • A SummaCare representative will contact you upon receipt of your application to discuss acceptance or denial of your application.
*Facility/Ancillary Name  
*Specialty  
Corporate Website
*Address  
*City  
State
*Zip  
*County  
Email
*Phone  
*Fax  

Additional Practice Address
Address
City
State
Zip
County
Do You Service Other Counties? Yes No
Please List All Counties
Phone
Fax
 
 
Do you provide Anesthesia Services?
Yes No

Are these services billed with your ancillary's Tax Identification Number?
Yes No

Please provide the following information regarding the group that provides this service at your ancillary:
Group Name
Contact Name
Contact Address
Contact Phone
Remit Name
Remit Address
Tax ID #
NPI
 
 
Do you provide Radiology Services at your ancillary?
Yes No

Are these services billed with your ancillary's Tax Identification Number?
Yes No

Please provide the following information regarding the group that provides this service at your ancillary:
Group Name
Contact Name
Contact Address
Contact Phone
Remit Name
Remit Address
Tax ID #
NPI
 
 
Do you provide Pathology Services?
Yes No

Are these services billed with your ancillary's Tax Identification Number?
Yes No

Please provide the following information regarding the group that provides this service at your ancillary:
Group Name
Contact Name
Contact Address
Contact Phone
Remit Name
Remit Address
Tax ID #
NPI
 
 
Do you provide Laboratory (Reference Lab) Services?
Yes No

Are these services billed with your ancillary's Tax Identification Number?
Yes No

Please provide the following information regarding the group that provides this service at your ancillary:
Group Name
Contact Name
Contact Address
Contact Phone
Remit Name
Remit Address
Tax ID #
NPI
 

Corporate Address
Corporate Name
Address
City
State
Zip
County
Phone
Fax

Remit Contact Address
*Remit Name  
*Address  
*City  
State
*Zip  
*County  
*Phone  
*Fax  
*Tax ID #  
*Remit NPI #  
Taxonomy Code
Taxonomy Code

Contracting Contact Address
*Contact Name  
Contact Title
*Contact Company  
*Email  
*Address  
*City  
*State
*Zip  
*County  
*Phone  
*Fax  

Credentialing Contact Address
Credentialing Name
Credentialing Title
Credentialing Company
Email
Address
City
State
Zip
County
Phone
Fax
Comments/Questions