Update Trading Partner Address

The Highmark Gateway, managed and maintained by Highmark, provides EDI capabilities for the payers listed below:

• Independence Blue Cross (54704), including products issued by Keystone Health Plan East (95056), or administered by Independence Administrators (TA720); see www.ibx.com/edi for greater detail.
• AmeriHealth−affiliated companies, including products issued by AmeriHealth HMO (95044), AmeriHealth Insurance Company of New Jersey including AmeriHealth PPO and Comprehensive Major Medical (60061), QCC Insurance Company d/b/a AmeriHealth Insurance Company including AmeriHealth DE − PPO (93688), or products administered by AmeriHealth Administrators (54763); see www.amerihealth.com/edi for greater detail.

Changes made on this form will update your trading partner information used for conducting business with only the payers listed above via the Highmark Gateway. You may have multiple Trading Partner IDs for use with Highmark and the payers it serves but this form applies only to the DataStream Trading Partner ID used for the payers listed above.

Requester Information    (Must be the Trading Partner Administrator)

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Your Name*:
Your Email Address*:

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Trading Partner Number*:
Trading Partner Name*:

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Street Address1*:
Street Address2:
City*:
State*:	Choose one Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip*:	-
Telephone Number*:	--
Extension:
Office Fax Number:	--
Email Address*:

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Please use this space for additional description or instructions.