Member Handbooks and Forms
Member Handbook
Forms
- Primary Care Provider (PCP) Form (PDF)
- Grievance Form (PDF) Effective 05/16/2023
- Appeal Form (PDF) Effective 05/16/2023
- Appointment of Authorized Representative Form (PDF)
- Notification of Pregnancy Member Form (PDF)
- Authorization to Use and/or Disclose Health Information - English (PDF)
- Authorization to Use and/or Disclose Health Information - Spanish (PDF)
- Revocation of Authorization to Use and/or Disclose Health Information - English (PDF)
- Revocation of Authorization to Use and/or Disclose Health Information - Spanish (PDF)
- SCDHHS Form 1716 - Request for Medicaid ID Number - Infant (PDF)
- Prescription Claim Reimbursement Form (PDF)
Resources
- South Carolina Healthy Connections Choices
- South Carolina Department of Health and Environmental Control (DHEC)
- Social Security
- Women, Infants and Children (WIC)
- South Carolina Department of Insurance (SCDOI)
- Food Stamps Program
- Big Brothers Big Sisters
- Member Quick Reference Guide (PDF)
- Service Area - Medicaid (PDF)
- National Hospice and Palliative Care Organization
- Preventive Guidelines
- Office Visit Checklist (PDF)
- My Health Pays Rewards (PDF)