Application for Blue Cross and Blue Shield of Kansas 834 Health Care Benefit Enrollments and Maintenance for Health and Dental
All fields are required except where marked (optional).
For questions about this form, please call the EDI Help Desk at 1-800-472-6481, option 1.
EDI Setup will be completed within 3-5 business days of receipt of this document. Once BCBSKS has completed setup; notification will be sent to email address provided in this form.
Notification will contain a confirmation letter containing the Employer Group Trading Partner Number and Data Matrix specific to the Employer Group. This information will be used in conjunction with the 5010 Companion Guide.
We strongly encourage both Employer Group and Vendor to sign up for Email List Notification.
Kansas law applies to this business relationship.
- back -