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.

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.
  • When you’ve finished filling out the form, save it, print it, and mail it, or fax it to the Health Insurance Marketplace at the location shown on the form.