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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  
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
Provider's Specialty
Taxonomy Code
Additional Provider's Specialty (if applicable)
Taxonomy Code
Provider's Individual NPI #
Provider's CAQH #
Provider's Hospital Privileges

No providers have been added.



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