Provider Forms
Provider credentialing forms
- Credentialing and recredentialing forms
- Non-contracted provider form (PDF)
- State of South Carolina Ownership Disclosure form (PDF)
Medical authorization/notification forms
- Abortion statement form (PDF)
- Consent for sterilization (PDF)
- Delivery notification worksheet (PDF)
- Hysterectomy justification (PDF)
- Member consent for provider to file an appeal (PDF)
- Newborn prior authorization form (PDF)
- Pregnancy risk assessment form (PDF)
- Prior authorization request form (PDF)
- Universal 17P authorization form (PDF)
Pharmacy authorization forms
- Pharmacy prior authorization form
- Physician request form for hepatitis C therapies (PDF)
- Request form for short-acting opioid medications (PDF)
- HCPCS authorization form (PDF)
Behavioral health forms
- Autism spectrum disorder (ASD) treatment request checklist (PDF)
- Community support service (CSS) authorization checklist (PDF)
- Community support service (CSS) authorization request form (PDF)
- Certification of need - psychiatric hospital services for children under 21 (PDF)
Psychiatric residential treatment facility (PRTF) authorization request form (PDF)
SBIRT forms
- SBIRT - authorization to disclose PHI (PDF)
- SBIRT - referral form for DAODAS (PDF)
- SBIRT - referral form for SCDMH (PDF)
- SBIRT - Tobacco Quitline fax referral form (PDF)
- SBIRT - universal screening tool (PDF)
Other forms
- Authorization to Disclose Protected Health Information (PHI) (PDF)
- Authorization to Disclose Protected Health Information (PHI) - Spanish (PDF)
- Let Us Know program member intervention request form (PDF)
- Personal representative (PDF)
- Physician transfer of member request form (PDF)
- Provider claim dispute form (PDF)
- Provider refund claim form (PDF)
- 3M Health Information Systems (HIS) dashboards user access request form (PDF)
- 3M Health Information Systems (HIS) dashboards user guide (PDF)