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 review your information and email you regarding acceptance or denial of your application. Please remember to check your SPAM folder and keep in mind that it will be approximately 90 days before you will receive a response. In the meantime, please contact SummaCare Provider Support Services at 800-996-8401 with any questions or concerns. 
*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

(include address if different than primary location 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

(include address if different than primary location address)
*Contact Name  
*Contact Title  
*Contact Company  
*Email  
Address
City
State
Zip
County
*Phone  
*Fax  

Credentialing Contact Address

(include address if different than primary location address)
*Credentialing Name  
*Credentialing Title  
*Credentialing Company  
*Email  
Address
City
State
Zip
County
*Phone  
Fax

 

Additional Information