BCBSKS EDI Change of Information form

This form may be used to change Trading Partner demographic information, enroll additional NPI or to change vendor information.

*=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 NPI
	Change Trading Partner Information

Billing NPI

Payer = Blue Cross and Blue Shield of Kansas

Choose Transaction:

NPI #
Provider/Group Name:

Add More Lines

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Blue Cross and Blue Shield of Kansas is an Independent Licensee of the Blue Cross and Blue Shield Association.
Blue Cross and Blue Shield of Kansas serves all counties in Kansas except Johnson and Wyandotte.
® Registered Trademarks of the Blue Cross and Blue Shield Association.

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