North Carolina and South Carolina Document Library

• Carolinas Broker Guide (PDF)
• Case Submission Checklist (PDF)
• HIPAA letter (PDF)
• HIPAA Authorization (for claims inquiries) (PDF)
• CAF (PDF)
• PAF (PDF)
• Compensation Form Instructions (PDF)
• 1099 Letter.pdf (PDF)
• Formulario de Inscripción / Cambio (Consolidado) (PDF)

• Group Enrollment Application (PDF)
• Risk Appraisal Questionnaire (PDF)
• HMO/POS Member Enrollment Application (PDF)
• Family Medical History Questionnaire (PDF)
• Supplemental Medical Questionnaire (PDF)
• North Carolina Medical Claim Form (PDF)
• Open Access Plus Enrollment/Change Form - English (PDF)
• Open Access Plus Enrollment/Change Form - Spanish (PDF)

• Group Master Data Sheet (PDF)
• Risk Appraisal Questionnaire (PDF)
• HMO/POS Member Enrollment Application (PDF)
• Family Medical History Questionnaire (PDF)
• Supplemental Medical Questionnaire (PDF)
• South Carolina Medical Claim Form (PDF)
• South Carolina Prescription Reimbursement Form (PDF)
• Open Access Plus Enrollment/Change Form (PDF)

Additional Products Available beginning 10/01/06

• Open Access CHMO Plan F (PDF)
• Open Access HMO Plan Comparison for 10/1/06 plans (PDF)

Additional Products Available beginning 08/01/06

• Open Access CHMO Plan 4 (PDF)
• Open Access CHMO Plan 5 (PDF)
• Open Access CHMO Plan 6 (PDF)
• Open Access POS Plan 8 (PDF)
• Open Access POS Plan 9 (PDF)
• Open Access POS Plan 10 (PDF)
• Open Access POS Plan 11 (PDF)
• Open Access POS Plan 12 (PDF)
• Open Access POS Plan 13 (PDF)
• Open Access CHMO Plan Comparison for 8/1/06 plans (PDF)
• Open Access POS Plan Comparison Grid for 8/1/06 plans (PDF)

Additional Products Available beginning 08/01/06

• Open Access CHMO Plan D (PDF)
• Open Access CHMO Plan E (PDF)
• Open Access POS Plan G (PDF)
• Open Access POS Plan H (PDF)
• Open Access POS Plan I (PDF)
• Open Access POS Plan J (PDF)
• Open Access POS Plan K (PDF)
• Open Access POS Plan L (PDF)
• Open Access CHMO Plan Comparison for 8/1/06 plans (PDF)
• Open Access POS Plan Comparison Grid for 8/1/06 plans (PDF)

Additional Products Available beginning 04/01/06

• HMO Comparison Grid for plans available beginning 10/1/2005 (PDF)
• POS Comparison Grid for plans available beginning 10/1/2005 (PDF)
• SC State Designed Basic CHMO Plan (PDF)
• SC State Designed Standard CHMO Plan (PDF)
• SC State Designed Basic Indemnity Plan (PDF)
• SC State Designed Standard Indemnity Plan (PDF)
• Open Access HMO Plan 1 (PDF)
• Open Access HMO Plan 2 (PDF)
• Open Access HMO Plan 3 (PDF)
• Open Access POS Plan 1 (PDF)
• Open Access POS Plan 2 (PDF)
• Open Access POS Plan 3 (PDF)
• Open Access POS Plan 4 (PDF)
• Open Access POS Plan 5 (PDF)
• Open Access POS Plan 6 (PDF)
• Open Access POS Plan 7 (PDF)
• Open Access Plus Plan A (PDF)

Additional Products Available beginning 04/01/06

• Open Access HMO Comparison Grid (PDF)
• Open Access POS Comparison Grid (PDF)
• NC State Designed Basic CHMO Plan (PDF)
• NC State Designed Standard CHMO Plan (PDF)
• NC State Designed Basic Indemnity Plan (PDF)
• NC State Designed Standard Indemnity Plan (PDF)
• Basic (PDF)
• Standard (PDF)
• Preference (PDF)
• Open Access HMO Plan A (PDF)
• Open Access HMO Plan B (PDF)
• Open Access HMO Plan C (PDF)
• Open Access POS Plan A (PDF)
• Open Access POS Plan B (PDF)
• Open Access POS Plan C (PDF)
• Open Access POS Plan D (PDF)
• Open Access POS Plan E (PDF)
• Open Access Plus Plan A (PDF)

Additional Products Available beginning 01/01/07

• HDHP Plan 1: 90%/2000 (PDF)
• HDHP Plan 2: 90%2500 (PDF)
• HDHP Plan 3: 90%/3000 (PDF)
• HDHP Plan 4: 100%/3000 (PDF)

Additional Products Available beginning 01/01/07

• HDHP Plan 1: 90%/2000 (PDF)
• HDHP Plan 2: 90%2500 (PDF)
• HDHP Plan 3: 90%/3000 (PDF)
• HDHP Plan 4: 100%/3000 (PDF)