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Gov. WEBPBSC-0289-17 January 2017 SC Medicaid XR PAB Fax Form 01. PAGE 1 OF 2 CONTINUED ON PAGE 2 www. BlueChoiceSCMedicaid.com BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan LLC an independent company for services to support administration of Healthy Connections. MEDICATION 4. STRENGTH 5. DIRECTIONS 6. QUANTITY PER 30 DAYS Specify 7. As a trial and inadequate response or...
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Patients are diagnosed with a specific medical condition or illness.
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Patient name, diagnosis, treatment plan, and provider information must be reported.
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