Blue Cross and Blue Shield
 

  ASK-EDI Forms

ASK Change of Information form

This form may be used to change Trading Partner demographic information, enroll additional provider numbers, or to change vendor information.
NOTE:
As of 12/1/07 – Requests to add provider numbers must include a valid NPI. Forms received without the NPI will be returned.

*=required
** = fax number or e-mail address is required

Step 1: Trading Partner Information  
Trading Partner Number : *
Organization (Legal) Name: *
Mailing Address: *
City: *
State: *
Zip: *
Contact Name(s): *
Phone #: ( ) *
Fax #: ( ) **
E-mail Address: **
Comments:


Step 2 : Identify Changes  
What do you need changed? Add New Vendor
  Add Additional Provider Numbers
  Change to Trading Partner information