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Logo Health Net of California, Inc. or delegate name [21281 Burbank Boulevard or delegate address 1] [Woodland Hills or delegate city, CA or delegate state 913676607 or delegate zip Preprimary Provider/Facility Primary

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How to fill out type 4-aptc authorization rescind

01

Obtain the Type 4-APTC authorization rescind form from the appropriate office or website

02

Fill out all required fields on the form, including your personal information and a detailed explanation of why you are rescinding the authorization

03

Sign and date the form to certify the information provided is accurate

04

Submit the completed form to the designated office or department for processing

Who needs type 4-aptc authorization rescind?

01

Individuals who have previously authorized the use of their Advanced Premium Tax Credits (APTC) for healthcare coverage and now wish to rescind that authorization

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What is type 4-aptc authorization rescind?

Type 4-aptc authorization rescind is a form used to revoke or cancel the advance premium tax credits (APTC) that were previously authorized for a health insurance plan.

Who is required to file type 4-aptc authorization rescind?

Individuals or households who no longer wish to receive APTC for their health insurance plan are required to file type 4-aptc authorization rescind.

How to fill out type 4-aptc authorization rescind?

To fill out type 4-aptc authorization rescind, individuals must provide their personal information, details of their health insurance plan, and the reason for revoking the APTC.

What is the purpose of type 4-aptc authorization rescind?

The purpose of type 4-aptc authorization rescind is to allow individuals to cancel or revoke the APTC that was previously authorized for their health insurance plan.

What information must be reported on type 4-aptc authorization rescind?

On type 4-aptc authorization rescind, individuals must report their personal details, information about their health insurance plan, and the reason for revoking the APTC.

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