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High Blood Pressure Program Satisfaction Survey
Page 1
Complete this short survey and you will be entered into a drawing for a $50 Walmart gift card!
The following fields are optional. We will need your name, ID# and phone number, however, if you wish to be entered into a drawing for a $50 Walmart gift card. **Disclosing your e-mail address is optional. By providing your e-mail address on this form, you are authorizing BlueChoice
®
HealthPlan to send you information related to health and disease managment programs via e-mail.
Name:
BlueChoice HealthPlan ID#:
Phone Number with Area Code:
E-mail Address:
BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association.