Download health coverage exemption forms

To fill out a health coverage exemption application, you’ll need to download it onto your computer first.

Step 1: Identify the correct form for you

• Right-click this exemption application form (PDF, 1.2 MB) link for hardship exemptions, like homelessness, bankruptcy, eviction, or foreclosure.
• Right-click this exemption application form (PDF, 1.1 MB) for affordability exemptions AND residency in:
  • Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, Wyoming
  • California, Colorado, Idaho, Kentucky, Maine, Massachusetts, Minnesota, Nevada, New Jersey, New Mexico, New York, Pennsylvania, Rhode Island, Vermont, Washington

  Step 2: Download the form on your computer

  • Download the form on your computer.
    • Chrome and Firefox users: Choose "Save Link As…"
    • Microsoft Edge users: Choose "Save Target As…"
    • Safari users: Choose "Download Linked File as…"

    Step 3: Open the form and fill it out

    When you’re ready to fill out the exemption application:
    • Minimize this web browser window.
    • Locate the exemption PDF document you downloaded to your computer in Step 2.
    • Click on the document to open it. You’re ready to start filling it out.
    • When you’re done filling out the form, print it and mail it to the Health Insurance Marketplace ® at the address shown on the form.

    Note: You may need to download the latest Adobe Reader software

    You’ll need to have a recent version of Adobe Reader software installed on your computer to open the exemption application. You may already have it. You have two options:

    • Follow the steps above. If you don’t have the right software installed, you’ll be sent to a page telling you to download it.
    • You can just download the latest version for free right now to be sure This link goes to an external site

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    More Answers: Download health coverage exemption forms

    What if I’m having trouble downloading the form?

    Double-check you’re following the download instructions for your web browser. You need to save the file to your computer before you can open it. If you’re still having trouble, contact the Marketplace Call Center.