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Provider / Become a Network Provider / Provider Application

Provider Office 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. 
  • If more than 8 Providers are in your group practice, please use the 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.
*Practice Name  
Corporate Website
Practice Type

Providers

Please fill out the following fields for each provider in the practice. When you have entered the information for a provider, click the "Add" button to add it to the list below.
Please list all providers in this practice.
Provider's Name
Provider's Degree
 
If you are not an MD or DO, please fax your Curriculum Vitae (CV) to 330-996-8801, with the subject of "App CV." Your may also email a copy of the CV to SCContracting@SummaCare.com Please use "App CV" in the subject line.
 
If you are a CNM, CNP, CNS or PA, who is your collaborating physician(s)?
(Please note: Your collaborating physician MUST be in the SummaCare Network.)
Enter Name, Practice/Group, Tax ID, and NPI on separate lines. (Separate entries with a line return.)
 
Provider's Specialty
Taxonomy Code
Board Certified? Yes No
Which board were you certified by?
Board Certification Expiration Date
To verify if you meet our credentialing criteria, please answer the following about your Post-Graduate Training:
Where did you do your internship?
(Facility name, city and state or country)
What Specialty is your internship under?
When did you do your internship? (mm/yyyy - mm/yyyy)
Where did you do your residency?
(Facility name, city and state or country)
What Specialty is your residency under?
When did you do your residency? (mm/yyyy - mm/yyyy)
Where did you do your fellowship?
(Facility name, city and state or country)
What Specialty is your fellowship under?
When did you do your fellowship? (mm/yyyy - mm/yyyy)
Additional Provider's Specialty (if applicable)
Taxonomy Code
Board Certified? Yes No
Which board were you certified by?
Board Certification Expiration Date
To verify if you meet our credentialing criteria, please answer the following about your Post-Graduate Training:
Where did you do your internship?
(Facility name, city and state or country)
What Specialty is your internship under?
When did you do your internship? (mm/yyyy - mm/yyyy)
Where did you do your residency?
(Facility name, city and state or country)
What Specialty is your residency under?
When did you do your residency? (mm/yyyy - mm/yyyy)
Where did you do your fellowship?
(Facility name, city and state or country)
What Specialty is your fellowship under?
When did you do your fellowship? (mm/yyyy - mm/yyyy)
Provider's Individual NPI #
Provider's CAQH #
Do you have hospital privileges? Yes No
List All Hospital Facilities


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

Secondary Practice Address
Address
City
State    
Zip
County
Phone
Fax

Additional Practice Address
Address
City
State    
Zip
County
Phone
Fax

Remit/Corporate Practice Address
*Name  
*Address  
*City  
State    
*Zip  
*County  
*Phone  
*Fax  
*Tax ID#  
*Group NPI#  

Contracting/Credentialing Practice Address
Contact Name
Contact Title
Email
Address
City
State    
Zip
County
Phone
Fax

Correspondence Address

(if different than Primary Location)
Name
Email
Address
City
State
Zip
Phone
Fax
Comments/Questions