Request Appointment

Thank you for your interest in Summa Health System. We look forward to serving you. With eight hospitals and 20 healthcare centers throughout our region, every effort will be made to find a physician conveniently located near you.
 
If you wish to call and speak to a patient-service representative directly, For patient information call: 855-345-4677

For all other requests call: 800-237-8662. If this is an urgent matter, please call 911.

Please compete ALL the information below so we provide you with optimal service.

Section One is about you.

Section Two asks for information regarding your health insurance plan.  

*Denotes Required Field.

PATIENT INFORMATION

I would like an appointment with: Summa Employed Doctor
Any Summa Affiliated Doctor
*First Name:
*Last Name:
Address:
City:
State:
Zip:
*Email:
*Home Phone:
Work Phone: (optional)
*Service Requested:
Location/Hospital Requested:
Physician Requested:
Other Information:

INSURANCE INFORMATION

Primary Insurance
Provider:
Group Number:
ID/Policy Number:
Provider Relations Phone Number:
Last Name of Primary Insured:
First Name:
Date of Birth:
Employer:
Employer's Phone Number:
Employer's Address:
City:
State:
Zip: