Update Address/Contact Information
This Trading Partner Business Center web form provides capabilities for the following Payers:
Highmark BlueCross BlueShield West Virginia
(54828),
Highmark Senior Solutions Company
(15459), and
West Virginia Family Health - Medicaid
(45276)
Changes made on this form will update your trading partner information used for conducting business with only the Payer which is linked to the Trading Partner ID you submit on this form. You may have multiple Trading Partner IDs for use with Highmark and the payers it serves but this form applies only to the Trading Partner ID that you enter below.
Requester Information
Your Name*:
Your Title*:
Your Company*:
Your Telephone Number*:
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Extension:
Your Email Address*:
Trading Partner Information
Trading Partner Number*:
Trading Partner Name*:
Trading Partner Address
Street Address1*:
Street Address2:
City*:
State*:
Choose one
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Zip*:
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Contact Name*:
Telephone Number*:
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Extension:
Office Fax Number:
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Internet E-mail Address:
Tax ID/Social Security Number*:
Additional Comments
Please use this space for additional description or instruction.