OmbudsContactForm 
(OVER) 1
Instructions:
UsethisformtocontacttheOmbudsOfficeifyourproblemorissuehasnotbeenresolvedby:calling
theServiceCenter,filingaCoveredCaliforniacomplaint,orfilinganappeal.Ifyouhavetriedoneofthe
methodslistedandstillhavebeenunabletoresolveyourproblem,TheOmbuds
Officecanresearch
yourcaseandhelpyoufindaresolution.Ifwecannothelpyou,wewillexplainwhywecouldnotor
referyoutoaresourcethatmaybeableto.
Questions?
Ifyouneedhelpinanotherlanguageorwouldliketocontactusoverthephone,calltheOmbudsOffice
at(888)7260840,CoveredCATTYat(888)8894500orEmailusatOmbuds@covered.ca.gov.
Informationaboutyou?
FirstName: LastName:
PrimaryContactNumber: SecondaryContactNumber:
Email:
MailingAddress:
City: State: Zip:
CaseID(optional): DateofBirth(optional):
Howcanwecontactyou?
Email Phone Mail
Ifbyphone,whenisthebesttimetocontactyou?
(Multipleoptionscanbeselected)
Morning:8amnoon MidDay:11am2pm
Afternoon:12pm5pm
Whatareyoucontactingusabout?
AccesstoCare Enrollment
AccountIssue GeneralQuestion
AppealsIssue Termination
AQualifiedHealthPlan Other
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2
Tellusaboutyoursituation(Optional‐Usemorepaperifyouneedmorespacetowrite)
ConsenttoreferthisformtoanotherDepartment/Organization:
TheOmbudsOfficemayhavetoreferthisformtoanotherstateagencyorconsumerassistance
group.Doyouagreetohaveyourinformationsenttoanotherstateagency/consumergroup?
Yes No
Returnthisformby:
Emailthisformto:
Ombuds@covered.ca.gov
Mailthisformto:
CoveredCalifornia
OmbudsOffice
1601ExpositionBlvd
Sacramento,CA95815
Faxthisformto:
(888)7260841
WhatHappensNext?
TheOmbudsOfficewillreviewyourformandrespondtoyouin13business days.Pleaseallowupto
5businessdaysformail.
Submit
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