Delete Provider Form

Highmark BCBS/Highmark BS
Adaptive Form Title
Delete Provider Panel

Delete Provider Panel

Delete Provider from Trading Partner

All fields with (*) are required

Select the tabs on the left to fill out the information in those sections

Requester Information

Requester Name*

Requester Title*

Requester Company*

Requester Telephone Number*

Requester Extension

Email Address*

Trading Partner Information

Trading Partner Number*

Trading Partner Name*

Provider Information

Request Type : Delete Provider

Enter Group NPI # :

Validation Result Message

Provider Validated hidden text field

Additional Comments

Please use this space for additional description or instruction. If removing ERA for a provider, you must include a valid contact within the provider's office (name, phone number and email address)