Join Our Network

Credentialing Applications

Thank you for your interest in joining the Heritage Summit HealthCare LLC network!

To complete the initial credentialing process, please submit the following information to us.

  • Completed application
    • Credentialing form - Provider (Word) ~ (PDF)
    • Credentialing & Recredentialing form - Hospital or Facility (Word) ~ (PDF)
  • Copies of the physician’s DEA license and medical license
  • Proof of medical malpractice insurance
  • Copies of board certification (if board certified)
  • Copies of medical diploma, internship and residency (if not board certified)
  • Curriculum vitae
  • Current W-9

Please submit completed forms to
Heritage Summit HealthCare LLC
PO Box 3623
Lakeland, FL 33802-3623
or
Fax: 863-665-5177