Forms Library

The below forms are for our historical enrollment process.

Use My Provider Enrollment Portal for all new enrollment.

Note: Use Microsoft Edge or Google Chrome to access the portal.

Use the individual checklist, group checklist or in state, out of network checklist to find all the forms and documentation needed for each practice type and network.

• Application For Clinic/Group/Institution/Location to File Claims or to Change Employer Identification Number (EIN)
• Authorization to Bill
• Change of Address
• Clinical Laboratory Amendment (CLIA) Certification Verification Form
• DBA Name Change
• Dental Credentialing Application – Non-medical dental providers (DDS) can apply for network enrollment using this form
• EFT Application and Terms and Conditions

• Health Professional Application - For out-of-network providers only
• Healthy Blue SM Credentialing Questionnaire - For enrolling and credentialing with Healthy Blue.
• Hold Harmless Agreement
• Hold Harmless Agreement, Chiropractors
• Nurse Practitioner Information Form
• NPI Update Form
• Provider Enrollment Application – New physicians and other health care professionals who want to join our networks can apply using this form.
• Registration Form for Mid-level and Hospital-Based Providers – For mid-level and hospital-based providers who want to join non-Medicaid networks. Do not use this form if you are also applying for the Healthy BlueSM (Medicaid) network. Use the Provider Enrollment Application.
• Request to Add or Terminate Provider Form
• Satellite Location Application
• South Carolina Uniform Managed Care Practitioner Credentials Update – Complete this form for recredentialing. Be sure to include the following documents:
  • Copy of your stat license(s)
  • Copy of your current DEA registration (if applicable)
  • Proof of current malpractice insurance/COI (must be a minimum of $1MM/$3MM)
  • CLIA Verification form (include a separate form for each location where you render lab services)

  Note: Return these items via fax to 803-870-9997 or email them to Recred.App@bcbssc.com.

  • Virtual Care Services Application – Complete this form for your practice to apply for participation with telemedicine and/or telehealth services.

  Note: Email the completed application with supporting documentation to VIRTUALCARE@bcbssc.com.

  BlueCross ® BlueShield ® of South Carolina is an independent licensee of the Blue Cross Blue Shield Association.