Forms Library

Forms Library

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. 
• 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
• Virtual Care Services Application – Complete this form for your practice to apply for participation with telemedicine and/or telehealth services. Email the completed application with supporting documentation to VIRTUALCARE@bcbssc.com.

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