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Welcome to Summit Health

Forms


Application forms

Summit Health Enrollment

Summit Health Extra Care Enrollment

Plan change forms

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

Plan change form

Disenrollment form

Transition of care

Use this form for a transition of care.

Transition of care form

Giving advance directive

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.

Get the Advance Directive form

Appointing a representative

You can assign someone you trust to request authorization, or file a claim, grievance or appeal.

Get the Appointment of Representative form

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Authorizing monthly electronic payment

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

Get the Authorization Agreement for Monthly Electronic Funds Transfer (EFT) form

Submitting a 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.

Get the pharmacy paper claim form

Submitting a medical claim

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

Get the medical claim form

Making a pharmacy coverage determination request

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:

Making a coverage redetermination request

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:

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

Last updated Dec. 17, 2020
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Contact us

Have questions? We’re here to help. Call us today at 844-827-2355 (TTY users, please call 711). Our customer service team is available from 7 a.m. to 8 p.m., Pacific Time, seven days a week from Oct. 1 to March 31. After March 31, your call will be handled by our automated phone system on weekends and holidays.

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