Federal Dentalblue Enrollment Form

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An Independent Licensee of the Blue Cross and Blue Shield Assocation
Alabama Federal DentalBlue
Enrollment Form
Failure to provide requested information may delay the processing of your application.
Please use black ink and print clearly.
Keep the bottom copy for your records.
Mail top copy to:
Blue Cross and Blue Shield of Alabama
Attention: Payment Processing - FEP
P.O. Box 2768
Birmingham, Alabama 35202-2768
1 800 492-8872
ENR-442 (Rev. 9-2011)

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