New 834 Enrollment Trading Partner Application
Your Telephone Number*:
Your Email Address*:
Trading Partner Information
Trading Partner Name*:
Office Fax Number:
Internet E-mail Address*:
Trading Partner Type
Employer / Sponsor
Third Party Administrator
Employer Contact Name*:
Employer Contact Title*:
Employer Contact Email Address*:
Software Vendor Information
Name of Software*:
Contact Telephone Number*:
Contact Email Address:
Please check this box if you do your own EDI Software programming.
Please use this space for additional description or instructions.
Acceptance and Submission
To continue the EDI enrollment process you must agree to the terms and conditions of Highmark's EDI services. If you already have a business relationship with Highmark, a new Agreement is not required.
New Highmark Trading Partner
By clicking on this checkbox and using these services, you accept, without limitation or qualification, the terms and conditions of Highmark's
EDI Trading Partner Agreement(s)
. Based upon your Trading Partner Type, you will be directed to the appropriate EDI Trading Partner Agreement(s) for your review.
Existing Highmark Trading Partner
If you already have a business relationship with Highmark, a new Agreement is not required. Please click the box below and enter your existing Highmark Trading Partner number so we may validate your relationship with Highmark.
Existing Relationship with Highmark
Current Highmark Trading Partner Number: