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The document is a notification form for reporting the death of an enrolled member in the Covered California health insurance program. It outlines the process for notifying Covered California about the deceased, including necessary information about both the deceased and the reporting member. The form also indicates that submitting this notification will lead to a redetermination of eligibility for remaining account members and provides instructions for submission.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (55 Votes)
2017	4.8 Satisfied (62 Votes)

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