To fill out this Marketplace Appeal Request Form (PDF), you’ll need to download it onto your computer first.
Step 1: Download the Marketplace Appeal Request Form
Step 2: Save the form on your computer
Download the form on your computer.
- Microsoft Edge, Chrome, and Firefox users: Choose "Save Link 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."
- Note: If you have problems downloading the form, contact the Marketplace Call Center 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. You’re ready to start filling it out.
Step 4: Submit the form by mail or fax
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.