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For security purposes, SummaCare requires that you provide specific information to confirm your identity in order to maintain confidentiality and protect the privacy of our members. Required fields must be provided in order to process your request. In the event you do not provide the required information, a SummaCare Representative will contact you by e-mail or phone requesting the missing information. To avoid delays, please provide all required information.

*Provider Name/Office Name  
*Tax ID  
*First and last name of person sending this request  
*Email Address    
*Phone Number
(include extension)
Member ID
(including 2-digit suffix)
Member Name
Date of service
Billed amount
Claim number
(if available)
Authorization number
(if applicable)