Privacy Statement

The information requested on this form is required by Covered California to assist with your request, and the information you provide will be used by Covered California solely for that purpose. Legal references authorizing the collection of the personally-identifiable information through this form include Sections 1798.22, 1798.25, 1798.27 and 1798.35 of the California Civil Code and Section 155.260(a) of the Code of Federal Regulations. California Health Benefits Exchange dba Covered California, 1601 Exposition Blvd, Sacramento, CA 95815 (800) 889-3871