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Recredentialing Applications

Approximately every three years, network providers must be recredentialed. Summit will contact you when this becomes necessary and ask you to submit the following documents.

  • A new, completed application
    • Recredentialing form - Provider (Word) ~ (PDF)
    • Credentialing & Recredentialing form - Hospital or Facility (Word) ~ (PDF)
  • Copies of DEA license and medical license
  • Proof of medical malpractice insurance
  • A new W-9

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