Download health coverage exemption forms
To fill out a health coverage exemption application, download it onto your desktop or laptop computer (not your phone or tablet).
Step 1: Download the correct form for your situation
When you select a form below, it will automatically download to your computer.
- Hardship exemption application form (PDF, 747 KB) for situations like homelessness, bankruptcy, eviction, or foreclosure.
- Spanish hardship exemption application form (PDF, 768 KB)
- Affordability exemption application form (PDF, 893 KB) if you live in:
- Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Hawaii, Indiana, Iowa, Kansas, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia, Wisconsin, Wyoming
- Spanish affordability exemption application form (PDF, 923 KB)
- Affordability exemption application form (PDF, 794 KB) if you live in:
- Colorado, Georgia, Idaho, Illinois, Kentucky, Maine, Massachusetts, Minnesota, Nevada, New Jersey, New Mexico, New York, Pennsylvania, Rhode Island, Vermont, Virginia, Washington
- Spanish affordability exemption application form (PDF, 777 KB)
Step 2: Open the form in Adobe Reader
- If you don't have Adobe Reader version 8 or higher, download the latest version for free.
- Locate the form on your computer. If you can't find it, check your "Downloads" folder.
- Select and open the document.
Step 3: Complete the form
Read the form instructions and fill it out. When you're done:
- Save your changes—Save the completed form to a folder or place on your computer where it will be easy to find later.
- Print and mail it to the Health Insurance Marketplace® at the address shown on the form.
If you're having trouble opening the form or filling it out, contact the Marketplace Call Center.