ASK: Change Form

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

Billing NPI/Provider Numbers
* New York customers must submit a valid 12 character provider number for both group and
individuals.
*Kansas and Kansas City customers - only billing provider numbers are required. Individual provider numbers are not needed unless they are used as the billing provider number.

Choose Transaction:

NPI # Provider #
Provider/Group Name:

Add More Lines

Add New Vendor
Company Name:	*
Mailing Address:	*
City:	*
State:	*
Zip:	*
Contact Name :	*
Phone #:	( ) *
Fax #:	( )
E-mail Address: