Welcome to Summit Health
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Use these forms if you would like to make changes to your existing Summit Health plan.
Use these forms if you would like to disenroll from your existing Summit Health plan.
If you are covered by other medical, vision, pharmacy or dental health plan, we coordinate benefits with other insurers to help you receive the full benefit of those plans.
Case management is a voluntary service for members experiencing complex conditions, catastrophic events or life altering event and need assistance in managing their situation with a Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or Behavioral Health (LCSW)specialist.
To make request case management, please call Summit Health case management at 833-460-0444. You can also email casemgmtrefer@yoursummithealth.com, fax a referral to 855-232-6904, or complete and submit our online referral form.
Transition of care form (English)
Transition of care form (En Español)
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.
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)
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 (En Español)
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 (En Español)
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)
If you need to request reimbursement for dental 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:
Last updated Oct. 1, 2023
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Call 844-827-2355 (TTY users, please call 711).
Our customer service team is available from 7 a.m.– 8 p.m. (Pacific Time), seven days a week October 1 – March 31 (closed on Thanksgiving and Christmas), and weekdays April 1 – September 30. Your call will be handled by our automated phone systems outside business hour.