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
*Address
*City
State
*Zip
*County
Email
*Phone
*Fax
Additional Practice Address
Address
City
State
Zip
County
Phone
Fax
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