Injured Workers Enrollment

Thank you for choosing Summit Pharmacy. Feel free to complete the form below, download a PDF version and fax to 877.678.5401, or enroll by phone at 877.678.5400.

Mail to:
2320 West Peoria Avenue, Suite D132
Phoenix, AZ 85029

My claim is:
Workers' CompensationAuto Accident

Fields marked with a * are required. Fields marked with a + are preferred but not required.

Personal Information
MaleFemale
 

 

Claim Information

 

Medical Information