Specialties/Other Forms

Specialty Forms

  • Centering Pregnancy Application Form – Providers can use this form to apply for participation in the Centering Pregnancy Program. Providers must have Centering Healthcare Institute membership and also be in the process of achieving Site Approval status. The Centering Healthcare Institute is a separate company that provides wellness education on behalf of BlueCross BlueShield of South Carolina.
  • Maternity Screening Referral Tool (SBIRT) – Providers can use this universal tool to identify pregnant women who need help with behavioral and problematic issues and refer them to treatment.
  • Pregnancy Notification Form – Complete this form to ensure members receive support early during pregnancy.
  • Radiation Therapy Treatment Form – Complete this form to notify BlueCross about radiation treatment for transition cases.

Other Forms

  • Authorization to Disclose Protected Health Information (PHI) to a Third Party – This is a Health Insurance Portability and Accountability Act (HIPAA)-compliant form that allows a member to grant permission for a provider to disclose PHI to BlueCross.
  • Designation of Authorized Representative to Appeal – This form is optional for use by any individual or physician to appeal on behalf of a member.
  • FEP Other Health Insurance Questionnaire – Federal Employee Program (FEP) members should complete this form to notify BlueCross of an additional health/dental coverage plan.
  • Other Health/Dental Insurance Questionnaire – Have your patient complete this form to give us information about possible other health/dental coverage, including Medicare, to process your claims correctly. A Spanish version of this form is also available. 
  • Peer-to-Peer Request Form – Peer-to-peer discussions are conversations between a physician and a health plan medical director. This discussion should focus on additional or new clinical information. Peer-to-peer discussions may be conducted when documentation does not support medical necessity or services are deemed investigational. Benefit denials are not eligible for a peer-to-peer discussion. We offer peer-to-peer discussions within five days of the initial notification. 
  • Subrogation Questionnaire – Members should complete this questionnaire when they receive treatment for an injury of illness that is work-related or the result of an accident. A Spanish version of this form is also available.

HEDIS Compliance Companion Forms

Complete the HEDIS Compliance Companion Forms to let us know about any care opportunities you may have provided for these measures. Doing so allows us to: 

  • Reduce the number of record requests you receive during the annual HEDIS effectiveness of care audit.
  • Target our educational outreach to members who need preventive of health services. 

Helpful Specialty/Other Information

  • Mental Health and Substance Abuse Treatment – For a complete list of mental health and substance abuse benefits forms, please visit Companion Benefit Alternatives’ (CBA) form resource center. CBA is a separate company that manages behavioral health and substance abuse benefits on behalf of BlueCross. (This link leads to a third party site. That company is solely responsible for the contents and privacy policies on its site.)
  • You can make it easy for members to update their other health information using computer access right in your office. Learn more.