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Physicians Enrollment

Thank you for choosing Summit Pharmacy.

  1. Fill out online enrollment form below with patient information, or download PDF and fax to (877) 678-5401 or call (877) 678-5400.
    Mail To:
    2320 West Peoria Avenue, Suite D132
    Phoenix, AZ 85029,
  2. Fax or FedEx prescription, along with enrollment form, directly to Summit Pharmacy. Summit must receive original prescription for all Schedule II narcotic medications only. Summit will provide prepaid Fed Ex envelopes and arrange all pick-up and delivery. DO NOT GIVE THE PRESCRIPTION TO YOUR PATIENT. *When enrolling motor vehicle accident patients, please include any necessary Assignment of Benefits and/or Letter of Protection forms.

    My claim is:
    Workers' CompensationAuto Accident

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

    Personal Information


    Claim Information


    Medical Information


    Please send submission confirmation email to:

    (Separate multiple addresses with a comma)