Filling out a Marketplace Appeal Request Form electronically

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

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

Step 2: Save 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."
• 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
  Attn: Appeals
  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.