To fill out this Marketplace Appeal Request Form (PDF), you’ll need to download it onto your computer first.
Right-click on this Marketplace Appeal Request Form (PDF).
Download the form on your computer.
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.
When you're ready to fill out the Marketplace Appeal Request Form:
When you’ve finished filling out the form, save it, print it, and mail or fax it to the Health Insurance Marketplace® at the following locations:
Mail in your appeal request form:
Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0061
Fax your appeal request to a secure fax line: 1-877-369-0130
Note: Currently email is not an option for submitting your form.