Marketplace Appeal Request Form D - Affordable Health Insurance ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'APPELLANT 1' section. Enter your first name, middle name, last name, date of birth, phone number, email address, and complete address details.
3. List any other household members who are also filing an appeal in the designated area. If there are more than four appellants, attach a separate sheet with their names.
4. In the 'Reasons for filing an appeal' section, clearly explain why you believe there was a mistake regarding eligibility. Be specific about the issues such as income or household size.
5. If applicable, provide information for an authorized representative who will assist you in this process. Fill out their contact details accurately.
6. Review all entered information for accuracy before signing at the bottom of the form. Ensure that all adults in your household have signed where required.

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