Complete this form for each printed enrollment kit to be mailed. Multiple kits must be requested separately, one at a time.This form is for internal Blue Cross and Blue Shield of Minnesota use only. Do not share the link externally. First Name: Last Name: County: --None--Aitkin Anoka Becker Beltrami Benton Big Stone Blue Earth Brown Carlton Carver Cass Chippewa Chisago Clay Clearwater Cook Cottonwood Crow Wing Dakota Dodge Douglas Faribault Fillmore Freeborn Goodhue Grant Hennepin Houston Hubbard Isanti Itasca Jackson Kanabec Kandiyohi Kittson Koochiching Lac qui Parle Lake Lake of the Woods Le Sueur Lincoln Lyon Mahnomen Marshall Martin McLeod Meeker Mille Lacs Morrison Mower Murray Nicollet Nobles Norman Olmsted Otter Tail Pennington Pine Pipestone Polk Pope Ramsey Red Lake Redwood Renville Rice Rock Roseau Scott Sherburne Sibley St. Louis Stearns Steele Stevens Swift Todd Traverse Wabasha Wadena Waseca Washington Watonwan Wilkin Winona Wright Yellow Medicine Outside MN N/A Mailing Address: City: State: Zip Code: Kit Request Type: --None--MAPD Meadow Region MAPD Lake Region MAPD Woodland Region Platinum Blue (Tsus Nqi) MA Only Freedom Blue Medicare Supplement MedicareBlue Rx
Complete this form for each printed enrollment kit to be mailed. Multiple kits must be requested separately, one at a time.This form is for internal Blue Cross and Blue Shield of Minnesota use only. Do not share the link externally.
First Name: Last Name: County: --None--Aitkin Anoka Becker Beltrami Benton Big Stone Blue Earth Brown Carlton Carver Cass Chippewa Chisago Clay Clearwater Cook Cottonwood Crow Wing Dakota Dodge Douglas Faribault Fillmore Freeborn Goodhue Grant Hennepin Houston Hubbard Isanti Itasca Jackson Kanabec Kandiyohi Kittson Koochiching Lac qui Parle Lake Lake of the Woods Le Sueur Lincoln Lyon Mahnomen Marshall Martin McLeod Meeker Mille Lacs Morrison Mower Murray Nicollet Nobles Norman Olmsted Otter Tail Pennington Pine Pipestone Polk Pope Ramsey Red Lake Redwood Renville Rice Rock Roseau Scott Sherburne Sibley St. Louis Stearns Steele Stevens Swift Todd Traverse Wabasha Wadena Waseca Washington Watonwan Wilkin Winona Wright Yellow Medicine Outside MN N/A Mailing Address: City: State: Zip Code: Kit Request Type: --None--MAPD Meadow Region MAPD Lake Region MAPD Woodland Region Platinum Blue (Tsus Nqi) MA Only Freedom Blue Medicare Supplement MedicareBlue Rx
