Covered California Forms
Covered California is the state-based health insurance marketplace in California. It was created as part of the Affordable Care Act (ACA) to provide a platform for individuals, families, and small businesses to shop for and enroll in health insurance plans. Covered California offers a range of health insurance options, including private health plans and government programs like Medi-Cal. Its primary purpose is to provide Californians with access to affordable and comprehensive health insurance coverage.
Documents:
45
PDF 
Word
This Form is used for small businesses in California to apply for coverage through Covered California for Small Business.
This form is used for filing a privacy complaint in California related to the Healthcare Exchange.
This form is used for applying for the Healthcare Evidence Initiative for your own household in the state of California.
This form is used for notifying the California Health Benefit Exchange (HBEX) about the death of an individual.
This form is used for filing a privacy complaint in California by a parent, guardian, or authorized representative.
This form is used for authorizing the release of personal information by an authorized representative in California.
This form is used for requesting information about how your personal information has been shared by a healthcare organization in California.
This form is used for requesting a record of disclosures of personal information by a parent, guardian, or authorized representative in California.
This form is used for parents, guardians, or personal representatives in California to request to amend personal information.
This form is used for requesting to amend personal information in California's health benefit exchange.
This form is used for applying for health insurance in California.
This form is used for applying for private health insurance in California. It is specifically designed for individuals who require large print materials.
This document is for individuals in California to file a complaint regarding bilingual services. It provides a formal way to address any issues or concerns with the provision of language assistance.
This form is used to request a state fair hearing in California to appeal a Covered California eligibility determination.
This form is used for notifying the California Health Benefit Exchange (HBEX) of the death of an individual by an estate representative.
This form is used for notifying the California Health Benefit Exchange (HBEX) about the death of an enrolled member. It is a way to inform the exchange about the change in the member's status.
This Form is used for filing complaints about bilingual services in California.
This form is used for applying for private health insurance in the state of California.
This document is used for employers in California to apply for enrollment.
Esta documentación es para el programa Covered California para pequeñas empresas, que proporciona seguro médico asequible a empleados de pequeñas empresas en California.
This document is used for filing complaints by employers or employees with Covered California Small Business (CCSB) in California. It provides a formal avenue for raising concerns or issues related to the CCSB program.
This form is used for filing a complaint against a Covered California Small Business (CCSB) agent or agency in California. It provides a way for individuals to report any issues or concerns they have regarding their interactions with an agent or agency.
This document is an application form used by employers in California to enroll their small business in Covered California for Small Business (CCSB), which offers health insurance options for employees.
