Vermont Freedom Plan Direct Pay Application

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Subscriber Information
* First Name:
* Last Name:
* Social Security Number:
* Date of Birth:
* Gender:

Note: Address given here must be a "Physical Address" (911 address) and not a Post Office Box.
* Physical Address:
* City:
* State:
* Zip Code:
This is also my Mailing Address:
Please enter your mailing address here.
Mailing Address:

* Home Phone:
Daytime Phone:

* Membership Type:
* Marital Status:
* Action:
* Requested Effective Date:
* Coverage Option:
* Please select your employment status:
Is there a group insurance plan offered at your place of employment? If not employed, select "No."
Do you have existing health care coverage that you would be replacing with this coverage?
Are you currently a BlueCross BlueShield of Vermont customer?