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Appeal Form (A1)Please complete this Appeal Form by following the instructions in the companion document titled Appeal Form Instructions. Please read both documents carefully to ensure you submit
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Visit www.healthcare.gov and search for the appeal form instructions.
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Download the appeal form and read the instructions carefully.
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Fill out the appeal form with accurate and detailed information about your situation.
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Make sure to include any supporting documents or evidence that may help with your appeal.
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Submit the completed appeal form either online or by mail as instructed.

Who needs wwwhealthcaregovappeal-form-instructions-amarketplace appeal formshealthcaregov?

01
Individuals who have had their healthcare marketplace application denied or their coverage terminated and wish to appeal the decision.
02
People who believe they qualify for a special enrollment period but were denied by the marketplace.
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The marketplace appeal forms on healthcare.gov are used to request a review of certain decisions made by the health insurance marketplace regarding eligibility, enrollment, or financial assistance.
Individuals who have received a determination or notice from the health insurance marketplace that they wish to appeal, such as those denied coverage or financial assistance, are required to file these forms.
To fill out the appeal forms, applicants must provide personal information, details about the decision they are appealing, and any relevant supporting documentation as instructed on the form.
The purpose of the appeal forms is to allow individuals to contest decisions made by the marketplace that affect their eligibility for health coverage and financial assistance.
The forms require personal information like name, address, and date of birth, details about the decision being contested, and any supporting evidence that substantiates the appeal.
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