Forms and Documents

Health Insurance Applications

Applications With Financial Help (APTC)

Application (English)

Large Print Application (English)

Large Print Application (Spanish)

Arabic Application

Armenian Application

Chinese Application

Farsi Application

Hmong Application

Khmer Application

Korean Application

Russian Application

Spanish Application

Tagalog Application

Vietnamese Application

Applications Without Financial Help

Application (English)

Large Print Application (English)

Large Print Application (Spanish)

Arabic Application

Armenian Application

Chinese Application

Farsi Application

Hmong Application

Khmer Application

Korean Application

Russian Application

Spanish Application

Tagalog Application

Vietnamese Application

Appeal and Complaint Forms

Request for a State Fair Hearing to Appeal a Covered California Eligibility Determination

Covered California Complaint Form

Bilingual Services Complaint Form

Privacy Complaint Form

Privacy Complaint Form by a Parent, Guardian, or Authorized Representative

Ombuds Contact Form

Privacy

Authorization For Release of Personal Information & Appointment of Representative

Authorization for Release of Personal Information by a Parent, Guardian, or Authorized Representative

Authorization For Release of Personal Information & Appointment of Representative 

Courtesy Notification of Deceased

HBEX 1000: Opt Out of the Healthcare Evidence Initiative

Notification of Deceased by an Estate Representative

Notification of Deceased by an Enrolled Member

Privacy Complaint Form

Privacy Complaint by a Representative Form

Request for an Accounting of Disclosures of Your Personal Information

Request for an Accounting of Disclosures of Personal Information by a Parent, Guardian, or Authorized Representative

Request to Amend Personal Information

Request to Amend Personal Information by a Representative

Bilingual Services

Bilingual Services Information

Bilingual Services Complaint Form

Bilingual Services Complaint Form (Spanish)

Bilingual Services Policy

Bilingual Services Policy (Spanish)

Fact Sheets

APTC Information

Coverage Options Fact Sheet

Coverage Options Fact Sheet (Spanish)

Health Plan Names, Plan Name on ID Card and Provider Directory Reference Guide

Medicare and Covered California Fact Sheet

Medicare and Covered California Fact Sheet (Spanish)

Rights and Protection Brochure

Welcome Brochure

Welcome Letter

Form 1095-A Information

Read About IRS Form 1095-A

1095-A Dispute Form

COBRA

Federal COBRA Election Form for Group Health Coverage

FPL (Federal Poverty Level) Chart

2020 FPL Chart

Nondiscrimination

Arabic

Armenian

Chinese

Hindi

Hmong

Japanese

Khmer

Korean

Punjabi

Russian

Tagalog

Thai

Vietnamese

Personal Information

Request to Amend Personal Information

Self-Attestation and Eligibility-Determination Forms

Attestation of Income, No Documentation Available

Attestation of Non-Incarceration Status

Attestation of Medicare Eligibility and Enrollment Status

Attestation of Loss of MEC

Attestation of Moving Within California

Document Cover Page

Document Cover Page (Spanish)

Medicare Attestation Form (Spanish)

Sample Attestation Form: Moved Within California

Sample Attestation Form: Moved Within California (Spanish)

Sample Attestation Form: Loss of MEC

Sample Attestation Form: Loss of MEC (Spanish)

Speakers’ Bureau Requests

Speaker/Event Request Form

Consumer Protection

Consumer Protection Fact Sheet

Reporting Suspected Fraud

SEP Acceptable Documents

Protecting Our Consumers

Website Accessibility Certification


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