Checklists, Forms and Examples


These checklists can help guide you along the enrollment process.


The forms below apply to our prior enrollment process.

Note: Return the completed EDIG ERA Enrollment form to  

Note: Return the completed form to

Note: Do not use this form if you are also applying for the Healthy BlueSM (Medicaid) network. Use the Provider Enrollment Application.

Note: If you are adding a practitioner to your group/location(s), please refrain from submitting claims until you receive notification from our Provider Enrollment department that your request has been completed and updates have been made in our system. All claims submitted prior to the system update must be resubmitted for processing.

  • Satellite Location Application — Complete this form to notify BlueCross and BlueChoice of the creation of a new location for an enrolled group that wishes to file claims.
  • South Carolina Uniform Managed Care Practitioner Credentials Update — Complete this form for recredentialing. Be sure to include the following documents:
    • Copy of your state license(s)
    • Copy of your current DEA registration (if applicable)
    • Proof of current malpractice insurance/COI (must be a minimum of $1MM/$3MM)
    • Clinical Laboratory Improvement Amendment (CLIA) Verification form (include a separate form for each location where you render lab services)

Note: Return these items via fax at 803-870-9997 or email them to

Note: Email the completed application with supporting documentation to


These are examples of documents you may need to submit to us.


BlueChoice HealthPlan is an independent licensee of the Blue Cross Blue Shield Association. 

Important notice:

The forms below 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.

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