1-800-868-5200 (TRS 711)Mon., Tue., Thu., Fri.: 8 a.m. to 6 p.m. Wed: 10 a.m. to 6 p.m.
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To submit your online enrollment request, please complete the following information. If you are expecting multiple births you only need to complete this form once.
Fields with an asterisk (*) are required and must be filled out to process your request.