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Blue Choice

Request to Add or Terminate Practitioner Affiliation

Please complete this form to request the addition or termination of a health professional’s association with your clinic, group, professional association or institution for Preferred Blue® (PPC) and BlueChoice HealthPlan networks.

This form should be completed no more than 30 days after the addition, termination or change. If you are adding a provider not currently on file, you will also need to complete the Health Professional Application to File Claims.

If you have questions about this form, email Provider.Cert@bcbssc.com.

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



Required if would like notice that the requested changes have been made