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.
- 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
Note: Return the completed form to Provider.EFT@bcbssc.com.
- Health Professional Application - For out-of-network providers only
- Healthy BlueSM 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.