The below provider enrollment forms should be completed and submitted upon request to Provider.Requested.Info@bcbssc.com. These forms are only for provider enrollment applications that were submitted historically (email or fax).

For applications submitted through My Provider Enrollment Portal, all additional document requested should be completed and submitted inside the portal.

• Appendix D (BlueChoice HealthPlan) – Use this form if you wish to join the BlueChoice HealthPlan network.
• Authorization to Bill – Use this form to notify us that you have authorized a clinic, group or institution to bill for your services.
• Change of Address – Use this form to update the physical, pay to, correspondence or billing agency address.
• Clinical Laboratory Improvement Amendments – Use this form if you render laboratory services in your office.
• Dental Enrollment Application – Use this application if you wish to join our dental network.
• Doing Business As – Use this form to change the "doing business as" name of your practice.
• Electronic Funds Transfer – Use this form to set up electronic payments.
• Group Practice Application – Use this application if you wish to enroll your practice in one or more of our medical networks.
• Health Professional Application – Use this application if you are located in South Carolina, but wish to remain out-of-network, and want to file claims to us.
• Hold Harmless (BlueChoice HealthPlan) – Use this form if you wish to join the BlueChoice HealthPlan network.
• NPI Notification – Use this form if you are an out-of-state and out-of-network provider that needs to register your NPI with us.
• Nurse Practitioner Preceptor – Use this form to provide us with the preceptor information for nurse practitioners that wish to enroll in one or more of our medical networks.
• Provider Enrollment Application – Use this application if you wish to join one or more of our medical networks.
• Registration for Mid-levels – Use this application for mid-levels* that wish to join one or more of our medical networks.
• Request to Add or Terminate Practitioner – Use this form if you wish to add or terminate a practitioner's affiliation with your practice.
• Satellite Location Application – Use this application is your practice is enrolled with us and has a new location that wants to file claims.
• South Carolina Uniform Managed Care Application – Use this application to recredential with us (occurs every three years).
  • For recredentialing applications, include the following items with the application:
    • Copy of State license(s)
    • Current copy of Drug Enforcement Administration (DEA) registration
    • Current copy of malpractice insurance (Minimum of $1M/$3M)
    • Clinical Laboratory Improvement Amendment (CLIA) certification form
• Virtual Care Application – Use this application is you wish to render telemedicine or telehealth services.

*Mid-levels include nurse practitioners, physician assistants, certified registered nurse anesthetists, certified nurse midwives, clinical nurse specialists and hospital-based physicians.

Note: Claims should not be filed until all provider enrollment processes have been completed. In the event claims are submitted prior to completion and reject, they must be resubmitted for processing.