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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.
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