Update TP Address Form

Highmark BCBS/Highmark BS
Adaptive Form Title
Update TP Address
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Update TP Address
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Update Trading Partner Name and/or Address

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*

Reason For Deletion*

Validation Result Message [initially hidden; shown when needed]

TP Number placeholder [always hidden; set into Confirmed TP Number when Confirm button clicked]

TP Name placeholder [always hidden; set into Confirmed TP Name when Confirm button clicked]

TP Organization Code placeholder [always hidden; set into Confirmed TP Organization Code when Confirm button clicked]

TP Organization Description placeholder [always hidden; set into Confirmed TP Organization Description when Confirm button clicked]

Results for TP

Trading Partner Name:

Payer Name:

Type:

BX 835 Enabled? [Only visible when on BX 835 Enrollment form]

If this is the Trading Partner you wish to update, you must select Confirm to continue or you may Re-Enter a different Trading Partner number.

If you click the Re-enter button you will need to re-enter any information you may have already entered on this form.

Confirmation Message [initially hidden; shown when needed]

If you need to have your Trading Partner Name updated, please click the highlighted text.

Requester Information (Must be the Trading Partner Administrator)

Your Name*

Your Email Address*

You may update the Trading Partner Name, the Address/Contact Information, or both.

Updated Trading Partner Name (Optional)

Trading Partner Name

Updated Trading Partner Address/Contact Information (Optional)

If you update any of the address fields you must fill out all the required address fields

Street Address1*

Street Address2

City*

State*

Zip*

Telephone Number*

Extension

Email Address*

Additional Comments

Please use this space for additional description or instruction

The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association:

Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life, Highmark Senior Health Company or Highmark Care Benefits Inc.

Central and Southeastern PA:Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company.

Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield.

West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company.

Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield.

Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

All references to "Highmark" in this document are references to the Highmark company that is providing the member's health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.