BlueChoice HealthPlan of South Carolina, Inc. fax number

Fax destination details

Department

Privacy Official

Purpose

Submission of Authorization to Disclose Protected Health Information (PHI) to a third party; PHI disclosure authorization

Form

Authorization to Disclose Protected Health Information to a Third Party — AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION TO A THIRD PARTY

Address

BlueChoice HealthPlan of South Carolina, Inc., Attn: Privacy Official (AX-400), PO Box 6170, Columbia, SC 29260-6170

Website

Visit organization website

Before you send

• Confirm that this exact department handles your document or request.
• Check the organization website or call its main line for the current fax number.
• Include a cover sheet and any case, member, claim, or form reference required.
• Keep the delivery confirmation with your submission records.

Fill out member information (name, date of birth, address, member ID), specify recipient, scope of disclosure, purpose, expiration, and signatures. Return to BlueChoice HealthPlan of South Carolina, Inc., Attn: Privacy Official (AX-400). Fax to 803-264-0253. Mail to PO Box 6170, Columbia, SC 29260-6170.

Official form instructions are published as a downloadable file on the organization's website.