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: Download the form on your computer

  • Right click on this exemption application form (PDF) link.
    • 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 2: Open the form and fill it out

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

  • Minimize this web browser window
  • Locate the “hardship-exemption.pdf” document you downloaded to your computer in Step 1.
  • 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: