Summit Health Enrollment (English)
Summit Health Enrollment (En Español)
Use these forms if you would like to make changes to your existing Summit Health plan.
Disenrollment Form (En Español)
Coordination of benefits (COB) (English)
Coordination of benefits (COB) (En Español)
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)
Use this form for a transition of care.
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.
Dental claim form (En Español)
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 Oct. 1, 2022