Forms

Enrollment Application forms

2023

Summit Health Enrollment (English)

Summit Health Enrollment (En Español) 

Plan change forms

Use these forms if you would like to make changes to your existing Summit Health plan.

2023

Plan Change Form (English)

Plan Change Form (En Español)

Disenrollment forms

Disenrollment Form (English)

Disenrollment Form (En Español)

Coordination of benefits (COB)

Coordination of benefits (COB) (English)

Coordination of benefits (COB) (En Español)

Case management form

Case management is a voluntary service for members experiencing complex conditions or catastrophic events and need assistance from a case management registered nurse or behavioral health specialist.

Case Management Referral form (English)

Case Management Referral Form (En Español)

Transition of care

Use this form for a transition of care.

Transition of care form (English)
Transition of care form (En Español)

Privacy forms and resources

Access the PHI Authorization Form (allows Summit to disclose your health information to those whom you give us permission), Advance Directive (informs healthcare providers of your wishes for your care) and Appoint a Representative (to request authorization, file a claim, grievance, or appeal). Learn about our adherence to HIPAA privacy practices.

Visit Privacy Center

Authorizing monthly electronic payment

By completing this form, you give us permission to deduct your monthly premium from a bank account

Electronic Funds Transfer (EFT) form (English)

Electronic Funds Transfer (EFT) form (En Español)

Submitting a claim

Pharmacy claim

If you go to an out-of-network pharmacy, you can see if we are able to reimburse any of your costs by completing the pharmacy paper claim form.

Pharmacy claim form (English)

Pharmacy claim form (En Español)

Medical claim

If you need to request reimbursement for medical services, you may submit proof of payment and the itemized bill with this form.

Medical claim form (English)

Medical claim form (En Español)

Routine vision claim

If you need to request reimbursement for routine vision services (such as an eye exam and glasses) from Vision Services Plan (VSP), you may submit proof of payment and the itemized bill with this form.

VSP reimbursement form (English)

VSP reimbursement form (En Español)

Dental claim

If you need to request reimbursement for dental services, you may submit proof of payment and the itemized bill with this form.

Dental claim form (English)

Dental claim form (En Español)

Making a prescription drug coverage request

Initial coverage request (determination)

Coverage determination is a decision about whether or not a prescription drug is covered. To request coverage determination, you or your provider may do one of the following:

• Complete our  online Prescription drug determination request form
• Contact Summit Health Pharmacy Customer Service at 844-827-2355. TTY users, dial 711.
• Mail your request by completing this coverage determination and exception request form

Appeal a denied request (redetermination)

A redetermination request is an appeal of a denied coverage determination. To request coverage redetermination, you or your provider can do one of the following:

• Complete our online Prescription drug redetermination request form
• Contact Summit Health Pharmacy Customer Service at 844-827-2355. TTY users, dial 711.
• Mail your request by completing this prescription drug redetermination request form.
  
  

Filing a complaint with Medicare

We work to resolve any issues you may have. You can also file a complaint directly with the Centers for Medicare & Medicaid Services (CMS) by using their online form.

Get the Medicare online complaint form