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Use this form to apply to these BlueCross networks: Preferred Blue^®, State Health Plan and the Preferred Dental Network. You will also need to submit the following information along with this form:

1. State license(s)
   
2. Current DEA certificate
   
3. Proof of malpractice coverage, including supplemental coverage
   
4. Board Specialist Certificate, if applicable
   
5. Electronic Claims Filing Requirement form
   
6. NPI NPPES Confirmation Letter or e-mail
   
7. If this is a new office location, appropriate IRS documentation (Letter 147C, CP 575 E or tax coupon 8109-C) and NPI NPPES Confirmation Letter or e-mail for the new location. If this is a new satellite location, include the NPI NPPES Confirmation Letter or e-mail for the new satellite location.
   
8. A signed contract signature page for each network to which you wish to apply. Please e-mail cred.fax@bcbssc.com to request the current versions of our network contracts. 

Download the SC Uniform Credentialing Application. 

Need Contracting Information?
Request contracts and further information here.

Note: The SC Uniform Credentialing Application may be filled out online. You may also save the form to your computer. To complete your application, please print the form and mail or fax it, with the appropriate information as listed above, to the addresses included at the bottom of the first page of the form.