2022 Application

2021 Application

If you've had a Qualifying Life Event, such as a marriage or the birth or adoption of a child, you may qualify for a Special Enrollment Period. If you're a Blue Option member with a Qualifying Life Event, please complete the application and mail it to this address in order to add a spouse or dependent to your current policy:

BlueChoice HealthPlan

Attention: Membership (AX-425)

PO Box 6170

Columbia, SC 29260-9915

Authorization to Disclose Protected Health Information

Your privacy is important to us. In accordance with state and federal laws, we don’t share protected health information (PHI) without your consent. Use this form to authorize the release of PHI to a third party. Having this form on file will allow us to discuss your coverage with the person you list, without you having to give permission each time you want that person to contact us on your behalf.

Change Request Form

You can use this form to:

• Cancel your plan on the next due date
• Add/change your bank draft

Claim Form

There may be times when you travel outside our service area or receive emergency services out of network and wish to file a claim. This is the form you use. 

Dental Reimbursement Form

Use this form to receive your dental reimbursement. Please note that you have 3 months from the date of service to submit this form. 

Designation of Authorized Representative of Appeal Form

Use this form if you need to appeal a claim on behalf of someone else.

International Claim Form

Health and Wellness Authorization Form 

We offer a variety of disease and health education programs for the entire family. Please complete this authorization form to participate.

Online Other Health Coverage Questionnaire

This form gives us information about any other health coverage you may have that can affect how we pay benefits. This is also known as Coordination of Benefits (COB). You can complete this form online by logging into My Health Tookit^®.

Pharmacy Mail-Order Form 

This form offers you the convenience of ordering your prescription drugs by mail.

Pharmacy Reimbursement Form

There may be times when you need to file for a reimbursement regarding your prescription(s). This is the form you use.

Request for Benefit Extension for an Incapacitated Dependent

The information requested on this form aids in providing BlueChoice HealthPlan the necessary information to make a coverage determination.

Transition of Care Form

This form is for people with an acute injury or illness. Members or covered dependents need to get approval for this short-term benefit.