Enroll in a Blue Cross dental or vision plan

  • Step 1) Tell us about yourself
  • Step 2) Tell us about your household
  • Step 3) Choose a plan and payment
  • Step 4) Tell us if you have other dental and/or vision insurance
  • Step 5) Review notification and authorization information
  • Step 6) Review payment and billing information
  • Step 7) Sign the Application
  • Step 8) Producer Attestation
  • Complete

To purchase an individual and family dental or vision plan complete the enrollment form below and provide all required documents. You must be a Minnesota resident over the age of 18 or have a parent or guardian listed as a contract holder to enroll in a plan.

For help completing the enrollment form call 1-800-531-6685 (TTY 771) or schedule an appointment with a Blue Care Advisor.

I am a new applicant
I am currently enrolled in a Blue Cross Dental or Vision individual plan

Please note: Processing of your Application may be delayed if this form is not completed in its entirety.

When you include Social Security numbers (SSNs), we can process your Application more efficiently, but you are not required to include them for your dependents or yourself.

Gender
I have been a permanent resident of Minnesota for a minimum of 183 days
Will you or any other enrollee receive any premium or cost-sharing payments made by a specific person or entity, directly or indirectly, by any ineligible third party?
Ethnic Background
Race
Spoken Language
Written Language