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Filling out a Marketplace Appeal Request Form electronically

To fill out this Marketplace Appeal Request Form (PDF), youโ€™ll need to download it onto your computer first.

Step 1: Download the Marketplace Appeal Request Form

Right-click on thisย Marketplace Appeal Request Form (PDF).

Step 2: Save the form on your computer

  • Download the form on your computer.
    • Microsoft Edge, Chrome, and Firefox users: Choose "Save Link As โ€ฆ"
    • Safari users: Choose "Download Linked File as โ€ฆ"
  • Select a location on your computer to save this application โ€” on the desktop, in your documents folder, or somewhere else it will be easy to find.
  • Click "Save."
  • Note:ย If you have problems downloading the form, contact theย Marketplace Call Centerย for assistance.

Step 3: Open the form and fill it out

When you're ready to fill out the Marketplace Appeal Request Form:
  • Minimize this web browser window.
  • Locate the Marketplace Appeal Request Form (PDF) you downloaded to your computer in Step 2.
  • Click on the document to open it. Youโ€™re ready to start filling it out.

Step 4: Submit the form by mail or fax

When youโ€™ve finished filling out the form, save it, print it, and mail or fax it to the Health Insurance Marketplaceยฎ at the following locations:
  • Mail in your appeal request form:
    Health Insurance Marketplace
    Attn: Appeals
    465 Industrial Blvd.
    London, KY 40750-0061
  • Fax your appeal request to a secure fax line: 1-877-369-0130
Note:ย Currently email is not an option for submitting your form.