Use these forms if you would like to make changes to your existing Summit Health plan.
Use this form for a transition of care.
An Advance Directive lets healthcare providers know your wishes for your care. They would use the Advance Directive if you were unable to communicate. Use this form to give instructions about life support, appoint a representative and more.
You can assign someone you trust to request authorization, or file a claim, grievance or appeal.
By completing this form, you give us permission to deduct your monthly premium from a bank account
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.
If you need to request reimbursement for medical services, you may submit proof of payment and the itemized bill with this form.
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:
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:
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.
Last updated Dec. 17, 2020