Forms and Documents
Health Insurance Applications
Applications With Financial Help to Lower Your Monthly Premium
Large Print Application (English)
Large Print Application (Spanish)
Applications Without Financial Help
Large Print Application (English)
Large Print Application (Spanish)
Appeal and Complaint Forms
Request for a State Fair Hearing to Appeal a Covered California Eligibility Determination
Request to Correct or Dispute Tax Forms
Covered California Complaint Form
Bilingual Services Complaint Form
Privacy Complaint Form by a Parent, Guardian, or Authorized Representative
Privacy
Authorization For Release of Personal Information & Appointment of 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 by a Representative Form
Request for an Accounting of Disclosures of Your Personal Information
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 (Spanish)
Fact Sheets
Financial Help (APTC) Information
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
Form 1095-A / 3895 Information
Read About IRS Form 1095-A and 3895
COBRA
Federal COBRA Election Form for Group Health Coverage
FPL (Federal Poverty Level) Chart
Nondiscrimination
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
Medicare Attestation Form (Spanish)
Speakers’ Bureau Requests
Consumer Protection
Consumer Protection Fact Sheet
Online Suspected Fraud Complaint
Printable Suspected Fraud Form
Edit this card
Edit this component
Was this article helpful?
Thanks for your feedback.