Other Forms

Specialty Forms

  • Center for Pregnancy 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. 
  • COVID-19 Discharge Planning Checklist – This checklist will help identify discharge needs, overcome barriers and prevent readmissions for members that contracted COVID-19.
  • Designation of Authorized Representative to Appeal – This form is optional for use by any individual or physician to appeal on behalf of a member.
    This form does not apply to State Health Plan members because providers cannot appeal on a member's behalf.
  • Federal Employee Program (FEP) Other Health Insurance Questionnaire – 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. 

Independent Dispute Resolution (IDR)

  • Open Negotiation Notice - This form is for nonparticipating providers to dispute whether payment of the specified rate for certain services was appropriate in accordance with the No Surprises Act.
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