Forms & Documents

* Please note that Moda Health performs some administrative functions for Summit Health. Contact us if you need more help.

Administrative forms

• Electronic Funds Transfer / Electronic Remittance Advice Enrollment Form - Allows for electronic transfer of funds to a bank account in lieu of paper checks
• Medical/Vision Claim Form - A fillable PDF for a claim. You may want to consider electronic claim submission instead.
• Provider Data Form - Data about your office for our files
• Medical Provider Nomination Form - Nominate a provider for our panel. Please consider reviewing our panel needs first
• Provider Refund Submission - Submit a refund for over payment on a claim

General forms

• Advance Directive - A patient’s wishes for their care, should they be too ill or hurt to express it themselves
• Coordination of benefits form - Allows a partner’s or spouse’s coverage to help cover a procedure for a patient

• Transition of care form - For patients transitioning on to a new plan. This form may also be used for a continuity of care request form for providers terming from network.

• Provider diversity data - submit diversity, equity, and inclusion focused information for yourself (contracted practitioners)
• Clinic diversity data - submit diversity, equity, and inclusion focused information for contracted clinics/facilities
• Case management referral form
• Waiver of Liability - Medicare only
• Non-Contracted Provider Appeals & Provider Payment Disputes

Authorization forms

• Authorization form - authorization form (Summit Health)

Manuals

• Clinical Editing Policy Information
• Electronic remittance explanation codes
• Provider Manual (Requires login to Benefit Tracker)
• Secure Storage and Transport of PHI Policy
• Reimbursement Policy Manual

Behavioral Health forms

• Behavioral Health Authorization Request Form
• Case management referral form

Medicare Advantage Primary Care Incentive Program (MAPCIP)

• 2024 Summit Health MAPCIP
• 2024 Summit Health MAPCIP Provider Incentive Measure Guide