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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. Gov. WEBPBSC-0364-17 February 2017 SC Medicaid PAB Fax Form 01. 24. 17. docx 9. PHYSICIAN SIGNATURE Prescriber or authorized signature Date treating physician can determine what...

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4. If there are any specific instructions or requirements, follow them closely.
5. Double-check all the filled information for any errors or omissions.
6. Sign and date the form as required.
7. Review the completed form to ensure it is complete and all necessary attachments are included.
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