Use the forms below to "get on file" to process claims or to provide us with updated information.
You can complete the forms by downloading them and then clicking in each form field and typing your information. You can also save the forms to your computer. To complete your application, please print the forms, then sign and fax them to 803-264-4795. We will receive the information in a secure electronic inbox. If you have any questions about the forms, please email us at firstname.lastname@example.org.
Use these forms to file claims for the following BlueCross BlueShield of South Carolina plans: Preferred Blue®, State Health Plan, Federal Employee Program (FEP) and the Preferred Dental Network.
These forms are not applications to join any of the networks. They simply allow you to file claims to BlueCross. Submitting these forms is not a guarantee that we will pay the claims you file.
If you are interested in joining either our health plan or mental health networks, please visit the Credentialing page.
Who should complete this packet? Health care professionals or entities who want to file claims to us or make changes in the information that we have on file about them. Download the File Application Packet. This packet contains:
Use these forms to notify us of any changes in demographic information or any additions/deletions of providers to your staff. We use this information for claims processing and in our directories.
Request to Add, Terminate or Change Practitioner Affiliation
Who should complete this form? Both network and non-network health care professionals who wish to request the addition or termination of other health professionals' associations with their clinics, groups, professional associations or institutions, or to report if a practitioner is changing locations within a clinic, group, professional association or institution.
Request to Change Tax ID
Who should complete this form? Any network or non-network clinic, partnership, professional association, institution or other group that wants to let us know it is changing Tax ID numbers.
Change of Address Form
Who should complete this form? Any network or non-network providers who want to let us know they have changed locations or appointment phone numbers. You should also use this form to let us know you want to change the address to which we send payment for services.
Application for Satellite Location
Who should complete this form? Any network or non-network providers who want to let us know they have added a new location.
National Provider Identifier Notification Form
Who should complete this form? Any network or non-network providers who need to register their National Provider Identifier (NPI) with BlueCross BlueShield of South Carolina. For more information on NPI, go to the HIPAA Critical Center.