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 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. 
*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 First Name  
*Provider's Middle Initial  
*Provider's Last Name  
Provider's Previous First Name (if applicable)
Provider's Previous Last Name (if applicable)
*Provider's Degree  
 
Please forward your Standard of Care or Collaboration Agreement to SCContracting@SummaCare.com or fax to 330-996-8801. Please note: nurse applications will not be processed without this agreement and all names MUST BE legible.
 
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)/podiatrist?
(Please note: Your collaborating physician/podiatrist 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



If your certifying board is not listed above, please list it here.
Board Certification Initial Effective Date
Board Certification Expiration Date
Board Certification Number
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



If your certifying board is not listed above, please list it here.
Board Certification Initial Effective Date
Board Certification Expiration Date
Board Certification Number
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 #
(Please make sure your account is up-to-date, re-attested and SummaCare has access)
 
Do you have hospital privileges? Yes No
Please list CURRENT hospitals where you have admitting privileges
Please print the Hospital Coverage Agreement, fill out completely, sign and then return to SummaCare by fax to 330-996-8801 or scan and email to SCContracting@SummaCare.com.


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

Additional Practice Address

Address
City
State    
Zip
County
Phone
Fax

Additional Practice Address

Address
City
State    
Zip
County
Phone
Fax

Additional Practice Address

Address
City
State    
Zip
County
Phone
Fax

Additional Practice Address

Address
City
State    
Zip
County
Phone
Fax

Additional Practice Address

Address
City
State    
Zip
County
Phone
Fax

Additional Practice Address

Address
City
State    
Zip
County
Phone
Fax

Additional Practice Address

Address
City
State    
Zip
County
Phone
Fax


Remit/Corporate Address

Same address as Primary Practice Address
*Name  
*Address  
*City  
*State    
*Zip  
County
*Phone  
Fax
*Tax ID#  
*Group NPI#  

Contracting/Credentialing Contact Information

Same address as Primary Practice Address
*Contact Name  
*Contact Title  
*Email  
Address
City
State    
Zip
County
*Phone  
Fax

Correspondence Address

(include address if different than primary location address)
Name
Email
Address
City
State
Zip
Phone
Fax

Comments/Questions/Additional Information

Additional Information

*Required