Get fillable appeal form

Gov/marketplace-appeals to Get an appeal request form for other states. Learn more about Marketplace appeals. Page 1 of 4 Appeal Request Form Individual Please print in capital letters using black or dark blue ink only. The authorization is valid until the earlier of The resolution of the appeal or My written notification that I want any or all of my authorized representatives removed from this appeal. I m signing this form under penalty of perjury which means I ve provided true answers to all the questions and I ve answered to the best of my knowledge. Health Insurance Marketplace Dept. of Health and Human Services 465 Industrial Blvd. London KY 40750-0061 You may also fax the form to a secure fax line 1-877-369-0129. You ll receive...