Remember: Until you receive notification from SummaCare that your deduction is scheduled to begin, please
continue to pay your monthly plan premium.
By typing my name and providing today's date above, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
*If the individual cannot sign, a court-appointed Legal Guardian or person with Durable Power of Attorney for
Health Care (DPAHC), if authorized by state law, must sign this document. Attach a copy of proof of Legal
Guardian, DPAHC, or proof of authorization by state law.
*If authorization form is for two members, both members must sign and provide their ID numbers for proper
identification.
If you have any questions, please contact SummaCare Medicare Customer Service at 330-996-8885 or Toll-free
1-800-996-6250. TTY users should call 1-800-750-0750. From October 1 through March 31, a representative
will be available to take your call from 8:00 a.m. until 8:00 p.m., seven days a week. From April 1 through
September 30, a representative will be available to take your call from 8:00 a.m. until 8:00 p.m., Monday
through Friday. Outside these hours, you may leave us a message and a representative will return your call the
next business day.
SummaCare is an HMO and HMO-POS plan with a Medicare contract. Enrollment in SummaCare Medicare
Advantage Plans depends on contract renewal.
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