Update TP Administrator/Delegate Form

Highmark BCBS/Highmark BS
Adaptive Form Title
Update Administrator/Delegate

Update Administrator/Delegate

Update Trading Partner Administrator/Delegate

All fields with (*) are required

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

Trading Partner Information

Trading Partner Number*

Trading Partner Name*

Request Type*

Update Administrator

Add Delegate

Update Delegate

Delete Delegate

All requests must be submitted by the Trading Partner Administrator, except when a Delegate uses Update Delegate to add his or her own security question/answer pair.

Administrator Information

Your Name*

Your Title*

Your Company Name*

Your Telephone Number

Extension

Your Email Address*

For security purposes, EDI Operations will contact you and use your security question and answer to confirm your identity.

The Trading Partner Administrator can identify an additional Trading Partner Delegate who may act on the trading partner's behalf to request basic changes or information for this trading partner. An existing Trading Partner Delegate may update the Delegate Information to provide a security question/answer that will streamline your future EDI support.

Delegate Information

Delegate Name

Delegate Title/Function

Delegate Telephone Number

Delegate Email Address

FOR DELEGATE USE ONLY: In order to confirm your identity for security purposes, please choose one of the following security questions and provide your corresponding security answer. The security answer will enable us to more quickly provide you with trading partner support and information.

Security Question

Your Security Answer

Additional Comments

Please use this space for additional description or instructions.