BlueCross BlueShield of Alabama


(8 a.m. - 5 p.m. CST)

Alabama Federal DentalBlue Enrollment

Select Plan

Employee Information

This is our Service Benefit Plan Basic or Standard Option Enrollees Only.

Please complete all items on this application. Any information missing may delay processing your application.

To enroll in Alabama Federal DentalBlue you must reside in the service area of Blue Cross and Blue Shield of Alabama. If you enroll in the FEHB Basic Option, you will automatically be enrolled in Alabama Federal DentalBlue Basic Option. The same is true for Standard Option.

*First Name:  Maiden/Middle: 
*Last Name:  Suffix:
*Social Security Number (Only Numbers): 
*Date of Birth: 
  Please enter a date. Please enter a valid date (mm/dd/yyyy).

Mailing Address Information
*Home Mailing Address:  Address 2: 
*City:  *State: 
*Zip Code: 
*Phone Number: 
   -     Home   Cell
*Email address: 
Is your billing address different than your home mailing address? (If yes, please check.)
  Questions? Call us at 1-800-492-8872 (8 a.m. - 5 p.m. CST) This is a secure site.