BCBSKS EDI Change of Information form

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

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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