Download the health coverage exemption form

To fill out a health coverage exemption application, you’ll need to download it onto your computer first.

Step 1: Identify the correct form for you

  • Right click this exemption application form (PDF) link for hardship exemptions, like homelessness, bankruptcy, eviction, or foreclosure.
  • Right click this exemption application form (PDF) for affordability exemptions AND residency in:
    • Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Virginia, West Virginia, Wisconsin, Wyoming
  • Right click this exemption application form (PDF) for affordability exemptions AND residency in:
    • California, Colorado, District of Columbia, Idaho, Maryland, Massachusetts, Minnesota, New York, Rhode Island, Vermont, Washington

Step 2: Download the form on your computer

  • Download the form on your computer.
    • Chrome and Firefox users: Choose "Save Link As…"
    • Internet Explorer users: Choose "Save Target As…"
    • Safari users: Choose "Download Linked File as…"
  • Select a location on your computer to save this application – on the desktop, in your documents folder, or somewhere else it will be easy to find.
  • Click Save.

Step 3: Open the form and fill it out

When you’re ready to fill out the exemption application:

  • Minimize this web browser window
  • Locate the exemption PDF document you downloaded to your computer in Step 2.
  • Click on the document to open it. You’re ready to start filling it out.
  • When you’re done filling out the form, print it and mail it to the Health Insurance Marketplace at the address shown on the form.

Note: You may need to download the latest Adobe Reader software

You’ll need to have a recent version of Adobe Reader software installed on your computer to open the exemption application. You may already have it. You have two options: